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ATLAS    AND    EPITOME 

OF 

OPERATIVE 
OPHTHALMOLOGY 


BY 

PROF.  DR.  O.  HAAB 

of  Zurich 


AUTHORIZED  TRANSLATION  FROM   THE  GERMAN 
WITH    EDITORIAL    NOTES  AND   ADDITIONS 


EDITED    BY 

G.  E.  DE  SCHWEINITZ,  A.M.,  M.D. 

Professor  of  Ophthalmology  in  the  University  of  Pennsylvania 

Ophthalmic   Surgeon  to    the    Philadelphia    Hospital ; 

Ophthalmologist  to  the  Orthopedic  Hospital 

and  Infirmary  for  Nervous  Diseases 


With  30  Colored  Lithographic  Plates  and  J54  Text-cuts 


PHILADELPHIA— NEW   YORK— LONDON 

W.  B.  SAUNDERS   AND   COMPANY 

1905 


Copyright,  1905,  by  W.  B.  Saunders  &  Company. 


Registered  at  Stationers'  Hall,  London,  England. 


ELECTROTYPED  BY  PRESS  OF 

WESTCOTT  &  THOMSON,    PHILADA.  W.    B     SAUNDERS  &   COMPAC 


EDITOR'S  PREFACE. 


This  volume  forms  a  natural  and  admirable  conclusion 
of  the  series  of  Atlases  which  Professor  Haab  has  pre- 
pared and  published.  Beginning  with  a  thorough  discus- 
sion of  the  proper  construction  of  operation-rooms,  narcosis 
both  general  and  local,  sterilization  as  it  is  applied  to 
ophthalmic  instruments,  and  the  theory  and  practice  of 
disinfection,  the  main  operations  upon  the  eye  and  its 
appendages  are  described  with  characteristic  fidelity  and 
clearness.  The  thirty  colored  lithographic  plates  portray 
in  a  far  more  satisfactory  way  than  words  can  the  steps 
of  an  operation.  Next  to  seeing  an  operation  itself,  these 
are  of  value,  and  in  most  instances  give  a  view  of  lifelike 
accuracy.  What  is  omitted  in  the  colored  plates  is  sup- 
plied in  the  text  illustrations,  of  which  there  are  one  hun- 
dred and  fifty. 

As  in  the  previous  volumes  of  this  series,  one  is  im- 
pressed with  Dr.  Haab's  wide  experience,  admirable 
technic,  and  sound  judgment.  The  editor,  as  in  the  pre- 
vious books  of  this  series,  has  compared  the  translation 
with  the  original,  and  believes  that  it  conveys  with  faith- 
fulness the  author's  meaning.      Editorial   comments  are 

5 


6  EDITOR'S  PREFACE. 

placed  in  brackets,  and  a  few  operations  not  described  by 
Professor  Haab  have  been  inserted. 

This  book  should  prove  useful  not  only  to  students  of 
ophthalmology  who  may  not  have  the  opportunity  of 
witnessing  frequently  operations  upon  the  eye,  but  also  to 
those  whose  daily  work  is  concerned  with  the  operative 
side  of  ophthalmic  work. 
January,  1905. 


PREFACE. 


The  great  abundance  of  material  made  it  necessary  to 
exercise  a  certain  selection  in  this  Atlas  and  Epitome  of 
Operative  Ophthalmology.  I  was  guided  in  my  selection 
chiefly  by  my  own  practical  experience,  which  covers  a 
period  of  almost  thirty  years ;  but  let  me  say  at  once  that 
I  am  not  familiar  with  all  the  methods  of  operations  de- 
scribed in  this  work  from  personal  experience  with  them. 
In  the  case  of  most  of  them,  however,  I  have  determined 
their  advantages  by  testing  them  myself.  In  doing  so  I 
found  out  that  it  is  not  only  necessary,  but  also  most  in- 
teresting, for  the  operator  to  resort  from  time  to  time  to 
other  methods  besides  those  on  which  he  was,  so  to  speak, 
brought  up,  and  which  have  become  a  part  of  him. 

I  have,  therefore,  endeavored  in  this  work  to  describe 
the  various  operative  interventions  in  such  a  way  as  to 
enable  my  colleagues  to  vary  their  operative  procedures  as 
I  myself  have  done. 

As  a  rule,  mere  verbal  description  does  not  suffice  to 
give  a  clear  idea  of  operative  procedures,  and  pictorial, 
illustration  is  therefore  indispensable  in  this  kind  of  work  ; 
for  which  reason  a  copiously  illustrated  Atlas  is  most  desir- 
able. 


8  PREFACE. 

The  text,  which  has  been  condensed  until  it  contains 
only  what  is  indispensable,  is  intended  as  a  guide  to  stu- 
dents, practitioners,  and  ophthalmologists  in  the  technic  of 
operations  on  the  eve  and  their  various  modifications ;  and 
I  imagine  that  assistants  who  have  to  prepare  an  operation 
will  welcome  the  book  because  it  enables  them,  without 
loss  of  time,  to  get  a  general  idea  of  the  plan  of  an  oper- 
ation and  the  instruments  necessary  for  its  performance. 

In  order  to  demonstrate  the  usefulness  of  a  special 
method  of  operation  I  have  thought  it  advisable  to  give 
the  pictures  of  cases  after  recovery.  On  the  other  hand, 
I  have  omitted  many  geometric  drawings  of  plastic  oper- 
ations which  usually  embellish  the  chapter  on  Blepharo- 
plastic  Operations  in  most  of  the  current  works  and  text- 
books, but  which  are  more  likely  to  have  seen  the  light 
of  day  at  the  desk  than  on  the  operating-table,  and  are 
therefore  of  questionable  usefulness,  especially  since  the 
introduction  of  Thiersch's  method  of  skin-grafting  has 
made  so  many  changes  in  this  branch  of  surgery. 

The  illustrations  of  the  instruments  in  this  work  were 
obtained  by  reproducing  the  photographs  made  under  my 
direction  by  Messrs.  H.  and  E.  Butcher,  of  Zurich,  after 
reducing  them  one-tenth  ;  except  in  two  groups,  those  for 
Krönlein's  operation,  for  which,  on  account  of  the  size  of 
the  instruments,  a  reduction  of  one-half  was  found  to  be 
necessary.  The  instruments  which  are  here  represented 
were  obtained  in  the  course  of  years  from  the  following 


PREFACE.  9 

firms  :  Weiss  &  Son,  287  Oxford  street,  London,  W. ;  H. 
Windler,  Friedrichstrasse  133  a,  Berlin ;  H.  Wulfing- 
Liier,  6  Rue  Antoine-Dubois,  Paris ;  G.  Tiemann  &  Co., 
New  York  ;  and  Chambers,  Inskeep  &  Co.,  Chicago  ;  but 
I  do  not  pretend  to  say  that  other  instrument-makers  do 
not  also  furnish  very  good  instruments  of  the  kind. 

I  am  indebted  to  the  artist,  Mr.  J.  Fink,  for  the  prepa- 
ration of  the  remaining  pictures,  many  of  which  presented 
considerable  difficulties. 

I  am  also  indebted  to  the  publisher,  Mr.  Lehmann,  for 
his  efforts  in  connection  with  the  preparation  of  this  Atlas. 

0.  HAAB. 


LIST  OF  LITHOGRAPHIC   PLATES. 


Plate    1. — Introduction  of  a    Pencil  of  Iodoform   into  the    Anterior 

Chamber  in  a  Case  of  Infection  by  a  Foreign  Body. 
Plate    2. — Operation  for  Senile  Cataract. 
Plate    3. — Reposition   of  the   Iris  with  the  Spatula  at  the  End  of  an 

Operation  for  Senile  Cataract. 
Plate    4.  — Operation  for  Secondary  Cataract,  after  Bowman,  with  Two 

Needles. 
Plate    5. — Operation  for   Secondary  Cataract   with   Knapp's  knife   in- 
troduced through  the  Sclera. 
Plate    6. — Iridectomy  in  Glaucoma. 
Plate    7. — Inferior  Sclerotomy. 
Plate    8. — Advancement  of  the  Right  Interims  in  Divergent  Strabismus, 

after  Prince. 
Plate    9. — Enucleation  of  the  Eyeball. 
Plate  10. — Opening  of  the  Orbit  after  Krönlein. 
Plate  11. — Opening  of  the  Orbit  after  Krönlein. 
Plate  12. — Destruction  of  the  Orbit  by  Carcinoma  (Rodent  Ulcer). 
Plate  13. — Fig.  1. — Pagenstecher's  Ptosis  Operation. 

Fig.  2. — Gaillard's  Suture  in  Spastic  Entropion. 
Plate  14. — Fig.  1. — Blepharophimosis. 

Fig.  2.— Canthoplastic  Operation. 
Plate  15. — Fig.  1. — Ectropion  due  to  Facial  Paralysis  in  the  Second  Year 
of  Life. 
Fig.  2.— The  Same  Eye  after  Six  Months,  after  Median  Tar- 
sorrhaphy with  Szymanowsky's  Modification. 
Plate  16.— Senile  Ectropion  with  Senile  Cataract  (see  Plate  17). 
Plate  17. — Fig.  1.— Kuhnt's  Ectropion  Operation  in  Same  Patient. 

Fig.  2. — Same  Eye  Three  Months  after  the  Operation  and 
One  Month  after  Cataract  Operation  without  Iri- 
dectomy. 
Plate  18.— Fig.  1.— Senile  Ectropion. 

Fig.  2.— Same   Eye   Immediately   after    Kuhnt's    Ectropion 

Operation  with  L.  Mailer's  Modification. 
Fig.  3.— Same  Eye  Three  Weeks  Later,  after  Recovery. 

11 


12  LIST  OF  LITHOGRAPHIC  PLATES. 

Plate  19.— Fig.  1.— Severe  Cicatricial  Ectropion. 

Fig.  2. — The  Same  Eye  Six  Months  Later. 
Plate  20. — Fig.  1. — Cicatricial  Ectropion. 

Fig,  2. — Showing  the  Wound  before  the  Skin-grafting. 
Plate  21. — The  Same  Eye  Two  Weeks  Later,  after  Uninterrupted  Re- 
covery. 
Plate  22. — Enormous  Cicatricial  Ectropion. 

Plate  23.— The  Same  Eye  Three  Months  after  the  Last  Operation. 
Plate  24.— Fig.  1.— Cicatricial  Ectropion  after  a  Dog-bite. 

Fig.  2.— Condition  of  the  Eye  Fifteen  Months  Later. 
Plate  25. — Fig.  1.— Complete  Symblepharon  and  almost  Complete  Ankyl- 
oblepharon. 
Fig.  2.— Eecent  Burn  on  the  Lower  Portion  of  the  Conjunc- 
tival Sac. 
Plate  26.— Figs.  1,  2.— The  Symblepharon  which  had  Meanwhile  Devel- 
oped was  Treated  by  Operation. 
Plate  27. — Large  Carcinoma. 

Plate  28.— Shows  the  Patient's  Condition  when  Discharged. 
Plate  29.— The  Same  Patient  after  the  Carcinoma  had  Recurred  and  had 

again  been  Removed. 
Plate  30.— Fig.  1.— Extirpation  of  the  Tear  Sac. 

Fig.  2.— The  Extirpated  Tear  Sac,  which  had  probably  not 
been  Reached  by  the  Incision  and  Curettage  Re- 
ferred to. 


CONTENTS. 


PAGE 

General  Considerations 1? 

Hospital  Wards  and  Operating  Rooms        18 

Anesthetization 25 

Local  Anesthesia 26 

Sterilization,  Antiseptics,  and  Asepsis 33 

Bandaging 45 

Salivary  Infection     .    .    .    . 59 

Disinfection ...  68 

Instruments 76 

Operations  on  the  Globe 81 

Operation  for  Cataract 81 

Indications , 85 

for  Removal  of  Total  Juvenile  Cataract 102 

for  Total  Soft  Cataract  of  Adults 108 

for  Traumatic  Cataract 108 

for  Partial  Stationary  Cataract 112 

for  Seuile  Cataract 118 

Preparatory  Treatment 124 

with  Iridectomy 136 

without  Iridectomy 142 

Modifications 148 

Accidents  and  Mistakes 154 

Method  of  Applying  Dressing  and  After-treatment    ....  162 

Accidents  Interfering  with  Healing  of  Wound  After         .    .  163 

for  Secondary  Cataract 166 

Treatment  of  Operation  for  Senile  Cataract  by  Couching  and 

Depression 174 

Operative  Treatment  of  Dislocation  of  the  Lens 175 

Removal  of  the  Lens  in  High  Myopia 176 

Iridectomy 179 

Optical  Iridectomy 180 

For  Relief  of  Increased  Tension 186 

Sclerotomy 196 

13 


14  CONTENTS. 

PAGE 

Operations  on  the  Cornea,  Sclera,  and  Conjunctiva 202 

Eeruoval  of  Foreign  Bodies  from  Cornea 202 

Puncturing  the  Cornea 206 

Operation  for  Pterygium 208 

The  Utilization  of  the  Conjunctiva  to  Cover  Defects  in  the 

Cornea 210 

Tattooing  of  the  Cornea 210 

Eemoval  of  Dermoids .  212 

Staphyloma  of  Cornea      .        213 

Operations  in  the  Anterior  Chamber 215 

Separation  of  Anterior  Synechias 215 

Separation  of  Posterior  Synechia? 216 

Removal  of  Foreign  Bodies  from  the  Interior  of  the  Eye ....  216 
Eemoval  of  Spicules  of  Iron  from  the  Eye  (Magnet  Opera- 
tion)    216 

Eemoval  of  Foreign  Bodies  not  consisting  of  Iron     .    .    .  237 

Operations  Outside  of  the  Eyeball  .... 239 

Operations  on  the  Ocular  Muscles 239 

Strabismus 239 

Tenotomy  after  von  Gräfe 242 

Tenotomy  after  Arlt 245 

Tenotomy  after  Snellen 246 

Operations  on  the  Antagonist  of  the  Squinting  Muscle  .  .    .  249 

Knapp's  Method 249 

Weber's  Method 249 

de  Wecker's  Method 250 

Landolt's  Advancement 252 

Prince's  Operation 253 

Verhoeff's  Operation 254 

Worth's  Method 255 

Capsular  Advancement  after  de  Wecker 256 

Knapp's  Method 257 

Todd's  Method 258 

Brand's  Method 258 

Schweigger's  Method 258 

Roster's  Method 259 

Miiller's  Method 259 

Enucleation  of  the  Globe 265 

Eesection  of  the  Optic  Nerve 274 

Exenteration  or  Evisceration  of  the  Globe 275 

Artificial  Glass  Eyes 278 


CONTENTS.  15 

PAG  E 

Operations  on  the  Orbit 279 

The  Eemoval  of  Tumors  from  the  Orbit 281 

Krönlein's  Operation        284 

Exenteration  of  the  Orbit 291 

Operations  on  the  Lids  and  in  the  Conjunctival  Sac 295 

Operation  for  Ptosis 295 

Pagenstecher' s 297 

de  Wecker* s 297 

Dransarfs 297 

Hess' 298 

Pana's 300 

Motais' 300 

Eversbusch's 302 

Snellen's 303 

Wolff's 304 

Lapersonne's 305 

Elschnig's 306 

Gillett  de  Grandmont's 307 

Operations  for  Entropion 308 

Gaillard's  Suture 309 

Destroying  Roots  of  Cilia  by  Electrolysis  ........  309 

Spencer  Watson's 311 

Hotz's 311 

Entropion  Operation  with  Advancement  of  the  Levator 

Tendon 314 

Streatfield's 316 

Snellen's 317 

Hotz's  Tarsus  Excision  for  Trichiasis  of  Upper  Lid  ...  317 

Division  of  the  Tarsus  after  Panas 318 


Pfalz's 


319 


Ablation  of  Ciliary  Border  after  Flarer 320 

Displacement  of  Ciliary  Border  after  Jasche-Arlt    ....  320 

Operation  for  Blepharophimosis 321 

Canthoplastic  Operations 321 

Tarsorrhaphy 302 

Operations  for  Ectropion 323 

Snellen's  Suture 324 

Szymanowsky's m  304 

Kuhnt's  Operation 325 

Blepharoplastic  Operations 328 

Fricke's 329 


16  CONTENTS. 

PAGE 

Dieffenbach's 331 

Thiersch's  Method  of  Skin-grafting 332 

Operation  for  Symblepharon 337 

Operations  on  the  Conjunctiva 345 

Operations  on  the  Lacrimal  Organs 347 

Simple  Eversion  of  the  Lower  Lacrimal  Punctum  .  .    .  348 

Dacryostenosis 350 

Dilation  of  the  Nasal  Duct  by  Means  of  Sounds  ...  353 

Extirpation  of  the  Tear  Sac  . 357 


Literature 361 


Index 


OPERATIVE   OPHTHALMOLOGY. 


GENERAL  CONSIDERATIONS. 

Since  upon  the  .success  of  an  ophthalmic  operation, 
especially  an  operation  for  cataract  or  glaucoma,  depends 
not  only  the  sight  of  the  affected  eye,  but  also  that  of 
its  fellow,  because  any  operation  in  which  the  globe  is 
opened  may  be  followed  by  sympathetic  disease  of  the 
other  eye — for  these  considerations  an  operation  on  the 
organ  of  sight  is  fraught  with  great  responsibility  and 
should  not  be  lightly  undertaken.  For  most  people  blind- 
ness is  as  bad  as  death,  and  for  many  it  is  even  worse. 
As  an  operation  on  the  eye  may  often  be  exceedingly 
difficult  and  call  for  the  greatest  care  and  skill  on  the 
part  of  the  operator,  I  fully  agree  with  Snellen  when  he 
says  :  "  Although  it  is  true  that  the  operative  field  in 
ophthalmology  is  limited  and  most  of  the  operations  are  not 
formidable,  it  is  nevertheless  a  mistake  to  regard  operative 
ophthalmology  merely  as  a  part  of  minor  surgery  and 
within  the  scope  of  every  practitioner,  as  there  appears  to 
be  a  tendency  to  do  from  time  to  time.  When  an  opera- 
tion on  the  eye  fails  to  realize  the  patient's  hopes,  the 
eifect  is  often  more  tragic  than  death  itself." 

In  operations  on  the  eye  a  surgeon  must  be  cool,  de- 
liberate, and  experienced,  or  an  accident  is  very  likely  to 
happen  to  him  or,  rather,  to  his  patient.  He  must  also 
have  well-drilled  assistants  of  the  right  kind.  The  most 
important  operations  on  the  eye,  particularly  those  for 
cataract  and  glaucoma,  arc  peculiar  in  that  they  must 
be    performed    in    a    short    space   of   time ;    and    if  the 

2  17 


18  GENERAL   CONSIDERATIONS. 

operator  has  made  a  slight  mistake,  as,  for  example,  in 
the  size  or  position  of  his  incision,  it  is  often  difficult  for 
him  to  rectify  it.  Besides,  the  surgeon  is  very  much  de- 
pendent on  the  patient's  behavior,  which  frequently  spoils 
the  most  beautifully  planned  operation.  In  such  cases 
nothing  but  promptness  on  the  part  of  the  operator  to  do 
the  right  thing  and  the  greatest  presence  of  mind  will 
avert  disaster.  At  the  same  time  the  entire  operative 
field  must  be  kept  constantly  in  mind  during  the  entire 
operation — not  only  the  spot  where  he  happens  to  be  busy 
with  his  instruments.  It.  may  be  asserted  with  confidence 
and  with  entire  honesty  that  an  ophthalmic  surgeon,  be 
he  ever  so  experienced,  never  is  certain  when  he  begins 
an  uncomplicated  operation  for  cataract  how  it  will  end. 
This  feature  lends  a  special  character  to  this  operation, 
which  is  one  of  the  most  important  that  can  be  performed 
on  the  human  subject. 

Not  only  the  operation  itself,  but  the  after-treatment, 
the  subsequent  course,  and  the  question  of  recovery  are 
very  much  influenced  by  the  patient's  behavior.  In  the 
same  way  the  nursing  and  medical  treatment  which  he 
receives  are  important  features  in  bringing  about  the 
ultimate  result. 


Hospital   Wards  and  Operating    Rooms. 

The  question  of  efficient  nursing  and  treatment  is  much 
simplified  if  the  operating  room  and  the  wards  in  which 
the  patients  spend  their  convalescence  are  properly  ar- 
ranged. By  exercising  great  care  and  deliberation  in  the 
treatment  of  the  eye,  from  the  time  of  operation  until 
recovery,  excellent  results  may  be  achieved  even  under 
unfavorable  external  conditions  in  hospitals  and  operating 
rooms  which  fail  to  come  up  to  the  most  modern  require- 
ments. Of  course,  the  man  who  can  give  his  patients  the 
benefit  of  the  scrupulous  cleanliness  of  a  modern  hospital 
will  have  an  easier  conscience  during  the  operation,  and, 
on  the  average,  more  satisfactory  results  afterward,  pro- 


HOSPITAL    WARDS  AND   OPERATING  ROOMS.      19 

vided  the  nurses  and  assistants  are  thoroughly  imbued 
with  the  principles  of  modern  hospital  nursing  and  the 
modern  treatment  of  wounds  and  act  according  to  these 
principles.  The  condition  of  the  walls  and  of  the  floors 
has  no  special  bearing  in  ophthalmic  surgery  ;  but  the 
hands  of  the  nurses  who  take  care  of  the  patients  are  of 
the  utmost  importance.  For  that  reason  I  should  like  to 
mention — aside  from  the  well-known  architectural  ad- 
vances of  the  last  decades,  which  ought  to  be  found  in 
every  hospital — the  fitting  up  of  every  room  with  running 
hot  water  as  a  chief  requisite  or  at  least  a  great  advantage 
for  an  eye  dispensary  of  any  considerable  patronage.  If 
hot  water  and  soap  are  readily  accessible,  the  attendants 
will  have  no  objection  to  cleansing  their  hands  at  frequent 
intervals,  and  this  alone  is  of  value. 

It  has  also  been  found  desirable  in  our  clinic  at  the 
University,  which  has  now  been  in  operation  seven  years, 
to  have  two  rooms  adjoining  the  operating  room  for 
patients  that  have  just  undergone  operation,  especially  for 
cataract,  one  for  males  and  the  other  for  females.  The 
patient's  bed  is  rolled  into  the  operating  room,  the  opera- 
tion performed  while  he  is  in  bed,  and  he  is  then  taken 
back  to  his  room,  so  that  there  is  no  necessity  of  lift- 
ing him  from  his  bed  to  the  operating  table,  and  from 
the  latter  back  to  his  bed.  I  have  no  doubt  that  patients 
who  have  been  operated  upon  for  cataract  or  glau- 
coma may  be  allowed  to  walk  about  and  go  to  their 
rooms,  as  is  the  custom  in  some  hospitals,  without  any 
great  danger  of  harm  arising  therefrom ;  but  it  is  per- 
fectly evident  that  complete  rest  in  a  recumbent  posture 
immediately  after  the  operation  is  not  only  more  agreeable 
to  the  patient,  but  also  better  for  the  wound,  and  that  in 
any  large  hospital  it  is  more  convenient  simply  to  transfer 
the  patient  in  his  bed  from  the  operating  room  to  the 
ward  or  private  room.  Since  it  is  of  the  greatest  im- 
portance in  the  case  of  all  wounds  that  involve  division 
of  the  capsule  of  the  globe  to  get  primary  union,  if  pos- 
sible, during  the  first  twenty-four  hours  after  operation, 


20  G  FNE  BAL   CONSIDERATIONS. 

complete  rest  during  the  first  day  is  desirable.  The 
patient  himself  will  realize  the  importance  of  such  pre- 
caution better  if  the  rest  begins  immediately  after  the 
operation  and  he  is  not  allowed  to  walk  about  for  a  time 
before  he  begins  his  rest  in  bed.  In  my  private  clinic 
cataract  extraction  and  iridectomy  are  invariably  per- 
formed in  the  patient's  own  room,  and  subsequently  the 
latter  remains  quietly  in  his  bed.  This  was  also  the 
practice  of  my  esteemed  master,  Horner,  both  in  his  clinic 
and  private  work.  It  is  possible  that  this  practice  is  in 
part  responsible  for  the  fact,  which  has  always  been  a 
source  of  personal  gratification,  that  during  the  twenty- 
seven  years  of  operative  experience  (including  the  time 
when  I  was  an  assistant  to  Horner)  I  have  had  but  1 
case — two  years  ago — of  that  frightful  intra-ocular  hem- 
orrhage, which  so  treacherously  destroys  the  eye  imme- 
diately or  soon  after  cataract  operations. 

[An  operating  chair  or  table,  the  height  or  inclination 
of  which  can  be  altered  to  suit  conditions,  and  the  imme- 
diate surroundings  of  which  can  be  maintained  in  surgical 
cleanliness,  is  preferred  by  the  majority  of  surgeons. 
From  it  the  patient  can  be  lifted  readily  to  the  bed  he 
afterward  occupies  without  deleterious  effort  on  his  part. 
—Ed.] 

It  is  not  necessary  to  darken  the  room  of  a  patient 
recently  operated  upon.  All  that  is  necessary  is  to  arrange 
the  shutters  so  as  to  bar  out  any  glaring  light  that  would 
be  equally  unpleasant  to  the  normal  eye.  It  is  important, 
however,  to  see  that  the  ventilation  in  the  rooms  is  ade- 
quate, because  the  patients  are  often  old  and  their  respira- 
tion is  insufficient,  so  that  oxygenation  and  metabolism 
are  incompletely  performed. 

The  enforced  rest  during  the  first  period  should  be 
made  more  bearable  to  a  patient  who  has  been  through  an 
operation  for  cataract  or  glaucoma  by  giving  him  an 
electric  bell  to  hold  in  his  hand  ;  in  this  way  we  may 
guard  against  fright,  which  in  many  cases  is,  perhaps, 
the  precursor  of  post-operative  delirium,  especially  when 


HOSPITAL    WARDS  ÄND   OPERATING   ROOMS.      21 

both  eyes  are  bandaged.  It  is  possible  my  habit  of 
impressing  my  patients  with  the  advantage  of  the  bell, 
as  Horner  was  in  the  habit  of  doing,  is  responsible  for 
the  fact  that  this  complication  (aside  from  delirium 
tremens)  has  so  far  never  occurred  in  my  practice.  It 
has  the  additional  advantage  of  making  it  very  much 
easier  for  the  patient  to  remain  strictly  quiet  during 
the  first  twenty-four  hours  after  the  operation.  If  a 
patient  becomes  excited,  in  spite  of  the  fact  that  both 
eyes  are  bandaged,  the  bandage  must  be  removed  from 
the  other  eye  and,  in  the  case  of  one-eyed  persons,  from 
the  operated  eye  also,  a  wire  screen  being  applied  for 
protection. 

In  the  arrangement  and  illumination  of  the  operating 
room  the  same  rule-  are  to  be  observed  as  for  operat- 
ing rooms  in  general.  It  is  a  debatable  point  whether 
the  color  of  the  walls  should  be  as  bright  as  possible, 
in  accordance  with  modern  ideas  on  hospital  arrange- 
ments, <>r  dark  ;  because  in  the  latter  case  the  amount 
of  lateral  illumination  is  diminished  and  the  operator 
thus  secures  a  light  that  is  free  from  reflexes  and  more 
agreeable  to  the  eye,  as  well  as  better  adapted  for  cer- 
tain ophthalmic  operations.  Snellen,  after  a  number  of 
experiments  and  years  of  experience,  recommends  for  the 
walls,  floor,  and  ceiling  a  dark,  dull-black  background 
enlivened  with  a  dark-gray  pattern,  for  the  purpose  of 
making  a  more  agreeable  impression  (a  point  which  I 
consider  of  some  importance).  The  north  window  in  the 
room  Snellen  has  provided  with  four  parallel  shades, 
by  means  of  which  the  entire  window  or  only  a  part  of 
it  can  be  darkened.  I  have  also  tested  this  point  by 
way  of  experiment  and  operated  in  a  room  with  black 
walls,  which  was  generally  used  for  ophthalmoscopy.  It 
is  not  to  be  denied  that  any  operations  in  which  the 
corneal  reflex  is  an  important  factor  and  which  require 
the  operator's  fullest  visual  acuity  such  an  illumination 
of  the  operative  field  is  most  desirable  and  at  the  same 
time  grateful  to  the  eyes,  both  of  the  operator  and  of 


22  GENERAL   CONSIDERATIONS. 

the  patient.  To  be  consistent,  however,  the  assistants 
and  other  attendants  must  either  wear  black  gowns  or 
choose  their  positions  so  that  their  white  gowns  will  not 
reflect  the  light, 

But  as  we  also  have  to  perform  operations  in  which  a 
good  light  from  all  directions — such  as  surgeons  prefer  in 
their  operating  rooms — is  desirable ;  that  is  to  say,  opera- 
tions on  the  adnexse  of  the  globe,  especially  plastic  opera- 
tions, extirpation  of  the  lachrymal  sac,  Krönlein's  opera- 
tion, etc.,  it  is  wiser  to  steer  a  middle  course  and  arrange 
the  operating  room  somewhat  in  the  fashion  that  I  have 
adopted.  The  walls  should  be  a  light  gray,  not  entirely 
white ;  the  floor  a  gray  terrazo,  and  the  ceiling  white. 
There  should  be  a  large  double  window,  provided  with 
two  wooden  roller-shades  attached  outside  of  the  window, 
by  means  of  which  it  may  be  rapidly  darkened  more  or 
less  to  suit  the  exigencies  of  the  moment.  Since  the 
amount  of  light  that  enters  through  the  window  is  dimin- 
ished, the  brightness  of  the  walls  also  diminishes  ;  while 
at  the  same  time  sufficient  light  falls  on  the  patient  and, 
if  the  patient's  bed  is  moved  sufficiently  close  to  the 
window,  enough  light  will  fall  on  the  eye  from  the  side. 

With  regard  to  the  proper  exposure  for  the  operating 
room,  I  find  a  western  light,  which  circumstances  happen 
to  make  the  only  one  available,  very  satisfactory,  because, 
like  all  my  colleagues,  I  nearly  always  operate  in  the 
forenoon.  In  cloudy  weather  this  gives  a  better  light 
than  if  the  room  faced  the  north.  [In  many  American 
hospitals  operations  are  performed  late  in  the  afternoon, 
hence  western  light  would  often  not  be  satisfactory. 
Practically,  however,  the  lighting  by  daylight  of  ophthal- 
mic operating  rooms  is  unimportant  if  they  are  provided, 
as  all  should  be,  with  suitable  stationary  as  well  as  port- 
able electric  lights,  and  with  shades  for  darkening  the 
windows,  as  may  be  needed. — Ed.] 

Another  expedient  that  I  have  resorted  to  for  years  and 
wThich,  I  believe,  is  also  employed  in  many  other  clinics 
and  eye  hospitals,  is  to  perform  operations  which  require 


HOSPITAL    WARDS  AND   OPERATING  ROOMS.      23 

an  especially  good  light  and  as  accurate  vision  as  possible 
exclusively  with  electric  illumination  to  the  total  exclusion 
of  daylight ;  this  also  enables  one  to  control  the  position 
of  the  corneal  reflex  and  to  keep  everything  dark  except 
the  small  operative  field,  so  as  to  obtain  a  maximum 
visual  acuity  on  the  part  of  the  operator  and  a  maximum 
of  light  on  the  operative  field.  The  small  incandescent 
lamp  surrounded  by  a  metal  tube  concentrates  its  light, 
which  passes  through  a  strong  convex  lens  on  a  small, 
clearly  and  intensely  illuminated  spot,  and,  as  the  lamp  is 
provided  with  a  suitable  handle  and  receives  its  current 
from  a  portable  accumulator,  the  light  is  thrown  on  the 
operative  field  in  such  a  way  as  to  obviate  any  disturbance 
by  the  corneal  reflex.  The  attendant  who  looks  after  the 
light  must,  however,  pay  special  attention  to  one  point : 
the  lamp  unfortunately  soon  becomes  hot,  and  if  he  brings 
it  in  contact  with  the  patient's  face,  as  the  nose,  for  in- 
stance, he  may  suddenly  start  and  thus  endanger  the  suc- 
cess of  the  operation.  In  some  instances  it  is  therefore 
better  to  have  the  lamp  fastened  to  the  forehead,  as  prac- 
tised and  recommended  by  Czermak.  It  is  not  desirable 
to  be  without  artificial  illumination  in  secondary  operations 
for  cataract  and  other  difficult  cataract  performances.  To 
provide  against  the  accidental  failure  of  the  electric  light, 
I  use  a  gas  or  petroleum  lamp  and  a  large  convex  lens  to 
concentrate  the  light  on  the  operative  field,  as  I  did  many 
years  ago,  before  electricity  came  into  use. 

Suitable  illumination  is  so  very  necessary  in  many  opera- 
tions on  the  eye,  and  particularly  in  the  most  important 
ones,  that  the  operator  must  never  neglect  it  under  any 
circumstances.  In  support  of  this  fact,  only  one  example 
will  be  mentioned.  It  not  infrequently  happens  in  opera- 
tions for  cataract  that,  immediately  after  the  capsule  of 
the  lens  has  been  opened,  a  considerable  quantity  of  soft, 
cortical  material  from  the  cataract  escapes  through  the  in- 
cision. In  these  cases  the  compact  nucleus  of  the  cataract 
is  small,  and  does  not  present  so  readily  in  the  wound 
as  a  large  nucleus  when  the  attempt  is  made  to  deliver  it. 


24  GENERAL  CONSIDERATIONS. 

It  may  even  rotate  about  its  transverse  axis,  and  in  the 
attempt  to  force  the  delivery  by  carrying  a  suitable 
instrument  (scoop)  from  below  over  the  cornea,  with  a 
certain  amount  of  pressure,  it  not  infrequently  happens 
that  the  nucleus  slips  by  the  wound  and  lodges  against 
the  upper  ciliary  body.  If  the  operator  fails  to  notice 
this  unfavorable  position  of  the  nucleus  and  continues 
the  delivery  of  the  cataract,  the  nucleus  slips  on  into 
the  upper  part  of  the  vitreous,  and  can  not  be  brought 
out  again  even  with  the  aid  of  a  wire  loop,  the  opera- 
tion is  a  failure,  and  the  trouble  can  not  be  very  easily 
remedied  even  by  a  secondary  operation.  On  the  other 
hand,  if  the  operator  notices  in  time  this  tendency  on 
the  part  of  the  nucleus  to  slip  behind  the  wound — 
and  to  do  so  requires  good  vision — he  can  correct  it  by 
pushing  the  nucleus  down  again  with  the  knife  (fleam), 
and  as  soon  as  the  upper  edge  is  exactly  behind  the 
wound,  he  can  effect  the  delivery  by  exerting  pressure  on 
the  cornea. 

In  regard  to  the  operating  table,  it  is  important  that  it 
should  be  possible  to  lower  the  head  and  raise  the  foot 
rapidly,  because,  in  my  experience,  this  is  one  of  the 
most  important  procedures  when  there  is  trouble  with 
the  anesthetization.  In  other  respects  the  table  may  be 
constructed  in  any  way  that  suits  the  operator's  conveni- 
ence. It  should  be  made  entirely  of  iron  and  without  any 
upholstering,  both  for  the  sake  of  convenience  and  to 
save  time  in  cleansing  it.  This  feature,  however,  is  im- 
material so  far  as  the  healing  of  the  operative  wound  is 
concerned,  and  sensitive  patients  find  these  hard  tables, 
which  so  much  resemble  a  machine,  both  physically  and 
psychically,  most  unpleasant — another  reason  why  I  fre- 
quently operate  on  a  patient  in  bed,  but  I  shall  never 
perform  an  operation  under  general  anesthesia  in  bed, 
unless  under  very  exceptional  circumstances.  [So  many 
operating  tables  and  operating  chairs  are  now  manufact- 
ured, adapted  to  all  the  exigencies  of  ophthalmic  surgery, 
that  operations   performed   on   the  patient's  bed,  except 


ANESTHETIZATION.  25 

when  done  in  private  houses,  would  not  seem  to  many  sur- 
ge« >ns  commendable. — Ed.] 

Anesthetization. 

My  experience  with  this  important  subject  is  that 
the  ophthalmic  surgeon  will  do  well  to  restrict  him- 
self as  much  as  possible  in  the  use  of  general  anesthesia 
with  chloroform,  ether,  bromethyl,  or  ethyl  chloric!.  These 
anesthetics  are  all  dangerous,  whatever  may  be  their 
names,  and  especially  chloroform  and  ether,  the  latter 
perhaps  a  little  less  so  than  the  former.  [See  editorial 
note  on  page  28. — Ed.]  Chloroform  particularly  may 
in  certain  individuals  cause  death  with  lightning  ra- 
pidity, even  at  the  very  beginning  of  narcosis,  and  there 
is  no  way  of  recognizing  the  danger  beforehand.  As 
Laqueur  recently  pointed  out  in  connection  with  a  ease 
of  death  from  chloroform  anesthesia,  persons  with  a  large 
thymus  gland  are  particularly  predisposed,  and  it  is  well 
known  that  such  persons  may  die  suddenly  from  other 
causes,  which  in  some  cases  are  quite  trivial,  such  as  a  fall 
into  cold  water,  or  even  in  the  absence  of  any  recognizable 
cause.  Unfortunately,  enlargement  of  the  thymus  gland 
can  not  be  diagnosed  with  certainty  ;  but  Laqueur  points 
out  that  the  same  individuals  often  present  hyperplasia  of 
the  lymphatic  apparatus  in  the  pharynx  from  enlargement 
of  the  follicles  at  the  base  of  the  tongue  and  of  the  tonsils. 
The  presence  of  such  enlargements  has* a  more  serious 
bearing  on  anesthetization  even  than  a  valvular  heart- 
lesion. 

Another  feature  that  renders  anesthetization  more  dan- 
gerous in  operations  on  the  eye,  so  that  a  normal  patient 
is  in  constant  danger,  even  when  narcosis  is  properly 
carried  out,  is  the  fact  that  the  eye  is  so  slow  to  lose  its 
sensibility.  [The  eye  may  be  anesthetized  with  coeain. — 
Ed.]  The  general  surgeon  can  operate  on  the  trunk  and 
extremities  long  before  the  ophthalmic  surgeon  may  begin 
to  cut — if  he  really  wishes  to  operate  under  total  and  not 


26  GENERAL  CONSIDERATIONS. 

under  partial  anesthesia.  For  that  reason  many  ophthalmic 
surgeons  operate  under  partial  anesthesia,  although  they 
may  not  be  quite  conscious  of  the  fact.  In  my  experience 
even  etherization  is  not  without  danger  if  carried  to  the 
point  of  actual,  profound  anesthesia.  I  have  witnessed 
the  most  dangerous  collapse  from  ether  in  the  case  of  two 
women  :  One  of  them  had  a  moderate  goiter  and  was 
menstruating  at  the  time  of  the  operation  ;  in  the  other  I 
could  not  find  any  reason  for  the  accident,  which  almost 
ended  fatally.  In  both,  the  pulse  and  the  breathing  be- 
came worse  and  worse  during  the  operation,  and  the  most 
vigorous  measures  for  resuscitation  were  repeatedly  em- 
ployed to  avert  a  fatal  issue.  I  have  repeatedly  seen 
similar  grave  accidents  from  cardiac  weakness  in  chloro- 
form anesthesia.  In  several  cases  of  chloroform  and  ether 
anesthesia  cardiac  weakness  did  not  develop  until  after  the 
anesthetization  was  completed  and  the  patient  had  partially 
regained  consciousness ;  the  attendants  were  compelled  to 
continue  their  efforts  at  resuscitation  for  from  one-half  to 
one  hour.  For  this  reason  I  always  have  the  pulse  and 
respiration  carefully  watched  after  the  operation  when  a 
patient  has  had  a  general  anesthetic. 

Furthermore,  in  cases  of  enucleation  I  avoid  cutting 
the  optic  and  ciliary  nerves  while  the  patient  is  in  pro- 
found anesthesia,  and  prefer  not  to  take  this  final  step 
until  the  patient  begins  to  show  some  reaction.  For  fre- 
quently severe  collapse  has  occurred,  evidently  brought 
on  by  the  shock  which  immediately  followed  the  snip  of 
the  scissors. 

In  reviving  a  patient  who  has  gone  into  collapse  I 
have  found  it  useful  :  (1)  To  lower  the  head  and  trunk  as 
soon  as  possible ;  (2)  to  draw  the  tongue  forward  ;  and 
(3)  to  begin  artificial  respiration.  In  addition,  to  use  at 
the  same  time,  (4)  heart  massage  (vigorous  rhythmical 
pressure  on  the  precordial  region  in  time  with  the  heart 
beat) ;  also  occasionally  to  employ  injections  of  camphor 
oil.  In  several  cases  of  severe  cardiac  collapse  I  obtained 
very  favorable   results  by  (5)  completely   inverting   the 


ANESTHETIZATION.  27 

patient  so  as  to  place  him  as  nearly  as  possible  on  his 
head.  In  two  cases  of  this  kind,  in  which  artificial  respira- 
tion and  the  other  measures  referred  to  had  failed  to  give 
satisfactory  results,  it  was  demonstrated  with  the  accuracy 
of  a  physiologic  experiment,  that  inversion  of  the  patient 
was  followed  by  return  of  the  pulse  and  respiration  ; 
while  as  soon  as  he  was  laid  down  again  and  the  operation 
resumed,  collapse  recurred,  which  again  subsided  as  soon 
as  the  patient  was  inverted,  and  so  on,  several  times  in 
succession. 

In  the  end  both  patients  were  saved,  and  so  far, 
although  I  have  performed  many  operations  under  gen- 
eral anesthesia — fortunately  without  a  death  occurring — 
I  am  becoming  more  and  more  cautious,  because  in  the 
course  of  years  some  very  sad  cases  have  come  to  my 
knowledge,  even  cases  in  which  young  persons  died  from 
anesthesia  in  simple  operations  for  strabismus.  I  there- 
fore still  hold  to  the  opinion  given  by  me  publicly  years 
ago — namely,  that  it  is  not  permissible,  for  the  sake  of 
such  a  trivial  operation  as  that  for  strabismus,  to  risk 
a  patient's  life  by  total  anesthetization.  After  writing 
this  I  once  allowed  myself  to  be  persuaded  by  a  young 
woman,  against  my  own  injunction — although  it  is  true 
that  this  particular  operation  for  strabismus  was  a  com- 
plicated one  (tenotomy  and  advancement) — to  use  a  general 
anesthetic  (chloroform),  and  this  same  young  girl  barely 
escaped  dying  under  the  anesthetic.  Although  of  a 
blooming  appearance  and  possessed  of  perfectly  normal 
heart  and  lungs,  she  developed  a  very  bad  cardiac  weak- 
ness which  required  an  hour  of  most  energetic  treatment. 

It  is  my  rule  never  to  employ  total  anesthesia  un- 
less attended  by  at  least  two  assistants,  so  that  every 
resuscitating  procedure  may  be  performed  correctly,  vigor- 
ously, and  persistently  without  fatigue  on  the  part  of  the 
operator. 

I  formerly  used  bromethyl  [ethyl  bromid]  occasionally 
because,  owing  to  its  rapid  and  brief  action,  it  is  very 
convenient  for  many  cases ;  but  gave  it  up  entirely  after 


28  GENERAL   CONSIDERATIONS. 

witnessing  a  person  who  is  very  near  to  me  develop  grave 
cardiac  weakness  lasting  thirty-six  hours  (so  that  for  some 
time  the  pulse  could  hardly  be  felt),  after  anesthetization 
with  bromethyl  for  the  purpose  of  extracting  a  tooth  (at 
which  I  assisted).  The  attack  in  this  case  must  have  been 
due  to  bromethyl  anesthetization  and  could  not  be  at- 
tributed to  anything  else;  possibly  the  patient  may  have 
had  an  idiosyncrasy  for  the  drug.  Ethyl  chlorid  possibly 
has  some  advantages  over  bromethyl ;  but  I  have  never 
had  any  experience  with  it  in  operations  on  the  eye. 

For  short  operations  of  this  kind  primary  ether  anes- 
thesia has  been  recommended  and  when  successful  is  very 
convenient.  The  patient  is  made  to  take  ten  to  fifteen 
deep  inspirations  of  ether,  after  which  short  operations 
can  be  carried  out  without  giving  pain — as  I  have  often 
convinced  myself — and  the  patient  feels  as  well  as  before 
as  soon  as  the  operation  is  over. 

[Ether  is  far  safer  than  chloroform.  According  to 
H.  A.  Hare,  the  mortality  due  to  etherization  is  about 
1  in  20,000,  or,  according  to  the  combined  statistics  of 
Julliard  and  Ormsby,  in  407,553  cases  there  were  25 
deaths,  or  1  in  16,302.  Again,  to  quote  Hare,  compared 
with  this  statement,  the  record  of  chloroform  is  as  fol- 
lows :  The  mortality  based  upon  many  tens  of  thousands  of 
cases  in  which  chloroform  has  been  used  is  about  1  in  2039 
(Gurlt) ;  or,  according  to  the  combined  statistics  of  Jul- 
liard and  Ormsby,  in  676,767  administrations  there  were 
214  deaths  =  1  in  3162.  Chloroform  is,  therefore,  fully 
five  times  more  dangerous  than  ether.  The  practice  of 
beginning  an  anesthesia  with  nitrous  oxid  which  is  to  be 
continued  with  ether  or  chloroform  obviously  possesses 
many  advantages.  The  same  remark  applies  to  primary 
inhalation  of  ethyl  chlorid. — Ed.] 

I/OCal  Anesthesia. — In  view  of  what  has  been  said 
I  have  endeavored,  since  the  introduction  of  cocain,  to 
substitute  local  for  general  anesthesia  as  much  as  possible 
in  operating  on  the  eye. 

For  a  slight  operation  on   the  conjunctiva  and  cornea 


ANESTHETIZATION.  29 

the  installation  of  a  1  to  2  per  cent,  watery  solution  of 
cocain  for  from  five  to  ten  minutes  is  quite  sufficient ;  but 
for  excision  of  the  iris,  if  the  anesthetizing  action  is  to 
penetrate  as  far  as  that  membrane,  the  instillation  of  a  5 
per  cent,  solution  for  a  half  hour,  every  three  minutes,  is 
required,  and  the  eyes  should  be  firmly  closed  during  the 
intervals  between  installations,  so  as  to  prevent  the  cornea 
from  being  roughened  bv  the  action  of  the  cocain  and 
thus  having  its  transparency  impaired.  When  the  iris  is 
inflamed,  even  this  protracted  instillation  is  not  quite 
enough  ;  of  this  more  will  be  said  presently.  In  order  to 
perform  a  really  painless  operation  for  strabismus,  it  is 
necessary  to  inject  a  few  drops  of  a  3  to  5  per  cent,  solu- 
tion under  the  conjunctiva  at  the  spot  where  the  tendon  is 
to  be  removed  or  advanced.  After  that,  however,  the 
operator  must  wait  live  minutes  before  beginning,  and  it 
is  well  to  employ  this  time  in  distributing  the  fluid  by 
gentle  massage  of  the  lid,  so  as  to  prevent  its  bringing 
about  any  changes  in  the  operative  field  and  thus  rendering 
the  operation  more  difficult. 

Ever  since  the  year  188b*  I  have  used  this  subcon- 
junctival injection  of  cocain  in  operations  for  strabismus 
and  have  never  had  bad  results.  At  the  worst,  the  opera- 
tion is  occasionally  followed  by  a  little  vomiting  in  the 
case  of  sensitive  patients.  The  small  quantity  of  cocain 
is  amply  sufficient  to  render  the  tenotomy  and  advance- 
ment painless.  Whenever  cocain  is  injected,  however, 
especially  when  a  little  extra  quantity  is  required,  it  must 
be  remembered  that  even  cocain  may  be  dangerous  if  too 
great  a  dose  is  employed.  In  no  case  should  more  than 
0.05  gm.  be  used  altogether  in  operations  about  the  head  ; 
if  possible,  one  should  try  to  get  along  with  less.  We 
should  always  remember  the  sad  case  which  occurred 
when  cocain  first  came  into  use,  and  when  its  dangers 
were  too  little  known.  A  surgeon  injected  cocain  for  a 
trivial  operation  that  he  was  about  to  perform  :  the  patient 
immediately  died,  and  the  doch  >r,  overcome  by  the  calamity, 
sent  a  bullet  through  his  brain. 


30  GENERAL   CONSIDERATIONS. 

For  some  time  I  have  even  performed  enucleation  in 
suitable  eases — that  is,  in  non-inflammatory  cases,  when 
there  is  no  reason  to  suspect  adhesion  of  the  bulb  to 
Tenon's  capsule — practically  without  pain  after  the  injec- 
tion of  a  weak  cocain  solution  :  First  inject  a  consider- 
able quantity  of  the  fluid  at  the  four  insertions  of  the 
rectic  muscles,  and,  after  the  tendons  have  been  cut,  make 
an  injection  with  a  curved  needle  at  the  posterior  pole  of 
the  eye.  During  recent  years  a  weak  mixture  of  cocain 
and  eucain  has  been  used  for  this  purpose,  and  the  quan- 
tity injected  is  large  enough  to  give  the  concomitant  effect 
of  infiltration — anesthesia  after  Schleich.1 

This  method  is  even  better  and  less  dangerous,  especi- 
ally when  it  is  possible  to  inject  some  of  the  fluid  into 
Tenon's  space.  With  this  method,  also,  the  operator  must 
wait  five  minutes  before  beginning.  This  local  anestheti- 
zation in  enucleation  is  particularly  useful  in  the  numerous 
cases  in  which  the  operation  is  performed  on  account  of 
hemorrhagic  or  some  other  form  of  advanced  glaucoma ; 
for  such  patients,  as  a  rule,  have  diseased  blood-vessels 
and  a  diseased  heart — that  is,  defective  circulation,  and 
are  often  of  advanced  age.  For  the  enucleation  of  an  eye 
that  is  giving  pain,  Snellen  recommends  the  injection  of 
cocain  with  a  Pravaz  syringe  into  the  vitreous  body 
through  the  sclera,  and  asserts  that  this  materially  dimin- 
ishes the  sensibility  of  the  eye.  When  the  eyes  are  soft, 
as,  for  instance,  after  cyclitis,  the  procedure  at  the  same 
time  raises  the  tension  of  the  eye-ball  and  thus  facilitates 
the  operation. 

For  the  removal  of  the  lachrymal  sac,  a  preliminary 
injection  of  the  cocain  and  eucain  mixture  may  also  be 
recommended,  providing  the  operation  can  be  performed 
in  a  non-inflammatory  region.  The  fluid  must  be  injected 
slowly  and  a  considerable  quantity  must  be  used. 

1  Schleich  uses  a  stock  solution  of  eucain  ß  and  cocain  hydro- 
chlorate,  ää  0.5  gm.  (gr.  viij),  absolute  alcohol  4  gm.  (3,j),  distilled 
water  16  c.c.  (^ss).  Two  parts  of  this  solution  are  mixed  with  eight 
parts  of  freshly  boiled  water  in  a  graduated  pipet. 


ANESTHETIZATION.  31 

Local  anesthesia  is  considerably  more  difficult  in  acute 
glaucoma  or  acutely  inflamed  eyes  in  which  iridectomy  is 
to  be  performed.  In  such  cases  the  iris  is  extremely  sen- 
sitive, and  even  the  previous  injection  of  cocain  solution 
under  the  conjunctiva  at  the  spot  where  the  keratome  is  to 
be  introduced  into  the  anterior  chamber,  as  recommended 
by  Koller,  has  not  always  proved  sufficient  in  my  experi- 
ence to  enable  the  operator  to  seize  and  excise  the  iris 
without  giving  pain  and  causing  the  patient  to  move.  In 
such  cases  I  have  for  years  resorted  to  the  expedient  of 
using  pure  cocain,  taken  directly  out  of  alcohol  and  allowed 
to  crystallize,  so  that  it  is  perfectly  sterile,  using  a  German 
silver  spatula  for  the  purpose  of  introducing  it  into  the 
anterior  chamber,  and  applying  it  directly  to  the  iris  after 
I  have  made  the  incision.  In  that  way  the  pain  may,  as 
a  rule,  be  greatly  diminished  and  in  many,  although  not 
in  all,  cases  entirely  abolished.  Total  anesthesia,  which 
in  such  cases  of  acute  glaucoma  appears  to  be  very  much 
indicated,  and  is,  in  fact,  regularly  employed  by  some 
operators,  if  only  to  enable  them  to  carry  out  the  opera- 
tion quickly  and  methodically,  does  not  always  facilitate 
iridectomy — which  in  such  cases  should  be  made  above  the 
pupil  whenever  it  is  possible — as  much  as  is  desirable,  be- 
cause of  the  upward  rotation  of  the  globe.  Besides,  it  is, 
as  has  been  said,  dangerous  in  glaucomatous  patients. 

The  application  of  a  thin  layer  of  cocain  in  crystals  is 
a  method  that  I  have  employed  for  some  years,  even  in 
slight  operations  on  the  lids  and  on  the  globe,  in  which 
the  incision  is  made  through  the  conjunctiva  (removal  of 
chalazion). 

During  recent  years  cocain  has  gained  an  ally  in  the 
extract  of  the  adrenal  gland,  one  of  the  constituents  of 
which,  when  the  solution  is  applied  to  a  mucous  mem- 
brane, causes  vigorous  contraction  of  the  blood-vessels  in 
a  very  short  time.  This  prompt  constricting  action  is 
possessed  in  a  remarkable  degree  by  adrenalin  (Solutio 
adrenalini  hydrochlorici),  which  is  prepared  by  Dr.  Taka- 
mine,  in  America,  and  sold  by  Parke,  Davis  &  Co.,  in 


32  GENERAL  CONSIDERATIONS. 

New  York  and  London.  This  preparation  also  has  the 
advantage  of  being  stable  and  clean,  and  a  very  weak 
solution  of  it  possesses  a  marked  action,  as  I  discovered  long 
ago.  By  instilling  a  very  few  drops  of  adrenalin  at  in- 
tervals of  a  few  moments,  the  redness  can  be  made  to  dis- 
appear temporarily,  if  not  wholly  at  least  in  part,  from 
inflammatory  or  hyperemic  eyes.  After  this  has  been 
done,  the  cocain,  as  a  rale,  develops  its  action  more  readily. 
Whether  in  glaucoma  the  action  of  cocain  on  the  iris  can 
be  rendered  sufficiently  powerful  with  the  aid  of  adrenalin 
I  cannot  say,  as  I  have  not  had  sufficient  experience  in 
the  matter.  That  adrenalin  is  very  valuable  as  a  hemo- 
static I  can  confirm  from  my  own  experience.  Ophthalmic 
surgeons  have,  however,  long  been  familiar  with  artificial 
anemia  as  produced  by  clamping  the  lids  with  the  instru- 
ments devised  by  Desmarres,  Snellen,  and  Knapp,  and  the 
method  is  used  to  great  advantage  in  many  operations  on 
the  lids.  But  when  these  clamps  can  not  be  applied  to  the 
lids,  as  in  extirpation  of  the  lachrymal  sac,  and  sometimes 
in  operations  for  strabismus,  etc.,  the  use  of  adrenalin 
offers  distinct  advantages,  for  the  lids  and  surrounding 
tissues  are  extremely  vascular,  so  that  hemorrhage  is 
often  very  profuse  and  interferes  with  the  operation.  My 
experience  in  this  matter  has  taught  me  that  by  adding  to 
the  fluid  (cocain,  cocain-eucain)  which  is  injected  in  the 
tissues  underneath  the  conjunctiva,  etc.,  for  the  purpose  of 
inducing  local  anesthesia,  a  very  small  quantity  (1-2 
drops  of  adrenalin  solution),  it  is  usually  possible  to  re- 
duce the  hemorrhage,  especially  the  capillary  hemorrhage, 
in  the  most  welcome  manner.  Sometimes  it  is  possible  to 
render  the  tissue  practically  bloodless,  as,  for  example,  in 
Kuhnt's  operation  for  ectropion.  It  is  well  to  be  cautious 
with  the  dose  of  adrenalin  and  to  confine  one's  self  to  the 
minimum  that  is  required.  Adrenalin  chlorid  solution 
(Takamine)  directly  mixed  with  more  or  less  of  a  1  to  2 
per  cent,  solution  of  cocain  is  generally  used. 

[Very  satisfactory   local    anesthesia    can    be    produced 
with  beta-eucain  and  adrenalin  chlorid.     Professor  Arthur 


STERILIZATION,   ANTISEPSIS,   AXD  ASEPSIS.       33 

E.    J.    Barker   has   recently   recommended   the  following 
solution  : 

Pure  chlorid  of  sodium 0.8  gm. 

Beta-eucain 0.2  " 

Adrenalin  chlorid 0.001  " 

Distilled  water 100.  " 

If  as  much  as  50  c.c.  of  such  a  solution  were  injected, 
only  1J  grains  of  beta-eucain  and  1  mg.  of  adrenalin 
chlorid  would  have  been  employed.  In  many  operations 
around  the  eye  a  much  smaller  quantity  would  suffice. 
It  is  necessary  to  wait  from  fifteen  to  twenty  minutes  after 
the  injection  before  the  edema  disappears  and  the  full 
effect  of  the  adrenalin  chlorid  has  asserted  itself. 

Professor  H.  C.  Wood  suggests  that  the  efficiency  of 
these  solutions  might  be  increased  by  adding  to  them  not 
only  beta-eucain,  but  also  cocain. — Ed.] 

Whenever  the  capillary  bleeding  is  severe  enough  to  be 
troublesome  in  work  on  the  lids,  plastic  operations  in  the 
neighborhood  of  the  eyes,  extirpation  of  the  lachrymal  sac, 
and  the  like,  it  is  a  good  plan,  while  operating,  to  apply 
small  pledgets  of  cotton  saturated  with  adrenalin  cocain  to 
the  bleeding  points  from  time  to  time,  with  moderate 
pressure.  In  this  way  the  preliminary  injection  of  the 
hemostatic  fluid  into  the  tissue  can  be  supplemented  and 
less  adrenalin  will  be  required. 

One  of  the  most  important  and  most  difficult  tasks  of 
the  ophthalmic  surgeon  is  the  proper  management  of 

Sterilization,  Antisepsis,  and  Asepsis. 

The  battle  with  the  micro-organisms  which  interfere 
with  the  healing  of  wounds  must  be  carried  on  with  the 
same  weapons  in  operations  on  the  eye  as  in  other  surgical 
procedures  on  the  human  subject ;  and,  although  vigorous 
measures  are  required,  they  must  be  undertaken  with  due 
caution,  owing  to  the  delicate  structure  of  the  organ.  It  is 
most  important  to  fight  the  micro-organisms  at  the  right 

3 


34  GENERAL  CONSIDERATIONS. 

spot  and  at  the  right  moment ;  it  Mould  be  wrong  to  rely 
on  the  asepsis  of  the  operating  room,  the  sterilization  of 
instruments,  and  the  like,  and  overlook  individual  local 
peculiarities  of  the  operative  field  and  the  dangers  incident 
thereto.  In  cases  involving  the  opening  of  the  capsule 
of  the  globe  (cataract  extraction,  iridectomy,  etc.),  more 
than  in  any  other,  the  surgeon  must  carefully  determine 
beforehand  what  is  the  proper  thing  to  do  in  any  indi- 
vidual case — whether  the  aseptic  or  the  antiseptic  method 
is  to  be  used.  While  the  surgeon  must  practically  become 
a  pedant  in  the  observance  of  aseptic  and  antiseptic  pre- 
cautions, it  is  equally  important,  on  the  other  hand,  to 
guard  against  becoming  a  slave  to  routine. 

For  example,  it  would  be  quite  wrong  to  assume  that 
the  rules  followed  when  dealing  witli  a  cutaneous  region, 
which  is  so  cleansed  that  the  entire  operative  field  remains 
aseptic,  can  be  directly  applied  to  operations  on  the  eye  and 
will  result  in  aseptic  healing  of  the  wound.  Such  an 
assumption  is  wrong,  for  the  simple  reason  that,  as  will  be 
explained  more  in  detail,  the  ophthalmic  surgeon  is  never 
certain  that  he  is  operating  in  a  sterile  field.  Plence,  al- 
though he  may  have  taken  every  precaution  dictated  by  a 
scrupulous  aseptic  technic,  he  will  occasionally  have  trouble 
with  the  healing  of  his  wound  and  will  soon  realize  that 
the  eye  is  a  peculiar  region  as  regards  operations. 

It  is  true  that  even  before  the  period  of  asepsis,  when 
nothing  was  known  of  the  methods  of  fighting  microbes — 
that  is,  by  antisepsis  and  asepsis,  and  even  prior  to  the 
dissemination  of  a  clear  idea  of  the  elementary  principles  of 
cleanliness  in  operations  on  the  eye,  many  such  procedures, 
as  hundreds  of  observers  could  testify,  turned  out  remark- 
ably well.  Nevertheless,  however,  as  large  a  proportion 
as  twenty  or  even  thirty  out  of  every  hundred  eyes  per- 
formed on  for  cataract  went  blind  from  purulent  or  non- 
purulent inflammation  before  the  advent  of  antisepsis ; 
although  the  eye  has  fortunately  exhibited  a  marked 
tendency  toward  recovery  after  operative  and  traumatic 
wounds. 


STERILIZATION,  ANTISEPSIS,   AND  ASEPSIS.       35 

On  the  other  hand,  even  the  most  scrupulous  cleanliness 
and  the  observance  of  all  the  rules  that  have  been  set  up 
by  the  doctrine  of  sterilization  and  asepsis  in  the  treat- 
ment of  wounds,  do  not  always  suffice  to  guarantee,  as  it 
were,  an  uncomplicated  healing  and  completely  to  make 
good  the  loss  of  tissue  in  the  same  way  as  is  now  possible 
in  many  operations  which  are  much  more  dangerous  and 
extensive  and  were  never  even  attempted  before  the  period 
of  antisepsis.  We  have,  undoubtedly,  reduced  the  per- 
centage of  losses  in  cataract  operations  in  the  most  grati- 
fying manner,  from  20-30  per  cent,  to  1-2  per  cent.,  by 
adopting  the  modern  treatment  of  wounds  in  surgical  pro- 
cedures on  the  eye ;  but  we  have  not  yet  succeeded  in 
bringing  about  what  ought  to  be  the  aim  of  every  oph- 
thalmologist— namely,  to  reduce  it  to  zero  with  absolute 
certain  tv. 


To  judge  from  the  publications  found  in  modem  literature  bearing 
on  this  point,  it  might  almost  be  supposed  that  failures  in  surgical 
treatment  for  cataract  are  a  thins:  of  the  past.  This  optimistic  presenta- 
tion of  actual  conditions  is  partly  explained  by  the  fact  that  an  operator 
nowadays  may  easily  perform  at  least  100  or  even  200  successful  opera- 
tions for  cataract  without  losing  an  eye,  and,  if  he  makes  up  his 
statistics  from  such  a  favorable  series,  he  will  not  have  any  failures. 
An  experienced  ophthalmologist  will  in  this  respect,  however,  hold  to 
the  dictum  of  Knapp  that  "  If  the  statistics  are  large  enough,  every- 
thing is  possible" — r".  <?.,  if  a  surgeon  performs  on  a  sufficiently  large 
number  of  subjects,  he  will  see  everything  from  suppuration  to  sym- 
pathetic disease  of  the  other  eye.  Hence,  if  we  are  to  have  accurate 
statistics  on  this  question,  they  must  be  based  on  a  large  number  of 
cases,  as  was  done  by  Arlt  thirty  years  ago  when  he  gave  the  most  in- 
structive account  of  the  results  of  his  proceedings  for  cataract.  The 
reports  that  have  frequently  appeared  during  recent  years  from  indi- 
vidual clinics  to  the  effect  that  from  100  to  200  operations  for  cataract 
resulted  in  recovery  without  a  single  failure  prove  nothing  whatever  as 
to  the  method  employed,  since  the  same  figures  were  obtained  by 
Homer,  whose  technic  consisted  merely  of  cleanliness.  If  we  wish  to 
know  the  truth  about  the  percentage  of  failures  at  the  present  time,  we 
only  need  to  examine  the  literature  of  subconjunctival  injections  of 
bichlorid  of  mercury  and  salt  solution  and  the  literature  of  intra- 
ocular disinfection,  and  we  shall  see  how  often,  even  in  the  most  recent 
times,  suppuration  and  slowly  progressive  inflammation  in  instances  of 
cataract  have  been  combated  and  improved  by  the  above-mentioned 
methods,  or  have  continued  their  destructive  course  in  spite  of  them. 


36  G  EN  ERA  L   CONS  ID  ERA  TIONS. 

In  order  to  gain  a  clear  understanding  of  the  present 
state  of  these  questions  relating  to  the  treatment  of 
wounds  of  the  eye,  it  is  necessary  to  go  back  to  the  his- 
torical development  of  these  matters.  The  effort  to  im- 
prove the  results  on  the  eye,  especially  operations  for 
cataract,  and  render  them  more  certain,  date  chiefly  from 
A.  v.  Gräfe.  It  was  quite  natural  and  in  accord  with  the 
views  of  his  time  that  von  Gräfe  should  have  made  the 
most  of  the  mechanical  conditions,  particularly  the  size 
and  position  of  the  incision,  as  factors  in  bringing  about  a 
smooth  recovery.  For  even  at  that  time  it  was  easily 
observed  that  a  small  puncture  of  the  cornea  (paracentesis) 
rarely  resulted  badly,  especially  by  suppuration  ;  and  even 
after  the  somewhat  larger  incision  and  more  serious  in- 
terference involved  in  the  excision  of  a  piece  of  iris 
(iridectomy),  purulent  inflammation  was  quite  a  rare  event ; 
while,  on  the  other  hand,  it  not  infrequently  followed  the 
still  more  serious  operation  for  cataract,  in  which  the 
incision  has  to  be  made  three  to  four  times  as  large  as  in 
the  case  of  an  iridectomy.  As  at  that  time  it  was  not 
customary  to  perform  an  iridectomy  when  operating  for 
cataract,  it  was  quite  natural  that  the  size  of  the  corneal 
incision  was  made  chiefly  responsible  for  the  occurrence 
of  a  purulent  inflammation. 

Von  Gräfe,  therefore,  quite  naturally  and  logically  bent 
his  efforts  toward  diminishing  as  much  as  possible  the  size 
of  the  incision  in  cataract  operations.  But  at  the  same 
time — and  this  is  very  important — he  tried  to  make  the 
incision  of  such  a  shape  as  to  enable  the  wound  to  close 
up  and  the  edges  to  unite  as  rapidly  and  as  perfectly  as 
possible.  With  a  fine  instinct  he  thus  established  one  of 
the  fundamental  principles  of  the  healing  of  wounds, 
which  still  holds  good  at  the  present  day  and  which  was 
never  fully  understood  until  now.  The  reason  why  rapid 
and  perfect  closure  of  the  wound  is  such  an  essential 
condition  of  ultimate  recovery  will  be  seen  from  what 
follows. 

The  better  results  as  regards  suppuration  of  the  wound, 


STERILIZATION,  ANTISEPSIS,  AND  ASEPSIS.       37 

which  were  obtained  with  von  Gräfe's  "  linear  extraction," 
as  compared  with  the  results  obtained  by  means  of  the 
earlier  method  with  a  large  corneal  flap,  as  the  statistical 
reports  of  the  times  clearly  prove  was  the  case,  are,  in 
my  opinion,  chiefly  attributable  to  rapid  closure  of  the 
wound. 

Before  Lister  finally  pointed  the  way  for  the  proper 
treatment  of  wounds,  many  a  surgeon  did  his  utmost  to 
improve  the  conditions  of  wound-healing  by  insisting  on 
the  observance  of  the  greatest  possible  cleanliness.  The 
same  principle  was  adopted  by  ophthalmic  surgeons,  among 
whom  Horner  should  be  specially  mentioned.  He  re- 
duced the  percentage  of  failures  to  2.67  per  cent.,  as  is 
shown  by  the  statistical  report  of  more  than  1088  of  his 
cataract  cases.  Among  737  cases  of  uncomplicated  cataract 
on  which  he  operated  between  1870  and  1880  the  per- 
centage of  failure  was  only  1.6  per  cent.  From  1877  to 
1880  he  became  more  and  more  strict  as  regards  cleanli- 
ness. 

It  was  not,  however,  until  a  more  intimate  knowledge 
of  micro-organisms  and  their  influeuce  on  the  healing  of 
w^ounds  had  been  obtained  that  the  ophthalmic  surgeon 
obtained  the  proper  weapons.  It  was  far  from  easy  for 
this  new  knowledge  to  gain  recognition,  and  I  always  find 
it  most  instructive  when  I  remember  that  almost  thirty 
years  ago,  when,  as  Eberth's  assistant,  I  made  the  ac- 
quaintance of  the  pathologic  micro-organisms  during  a 
long  course  of  tedious  labor  with  my  revered  teacher  in  a 
pathologic  institution — even  though  hampered  by  the  ap- 
prehension of  ridicule  from  others — for  nobody  would 
believe  in  the  "stuff."  Then,  after  I  had  thoroughly 
learned  the  lesson  of  cleanliness  from  Horner,  and  the 
antiseptic  method  of  treating  wounds  from  R.  Volkmann, 
in  Halle  ;  and  Lister,  in  Edinburgh,  I  became  convinced 
that  equally  great  progress  could  be  made  in  the  treatment 
of  wounds  of  the  eye  as  in  other  operative  fields,  and, 
acting  on  this  conviction,  I  applied  the  principles  of 
Lister's  teachings  to  the  very  first  of  my  operations  in 


38  GENERAL  CONSIDERATIONS. 

1878,  not,  of  course,  without  modifying  them  to  suit  the 
delicate  structure  of  the  eye,  and  not  without  first  having 
tested  the  effect  of  carbolic  acid  on  the  eye  by  means  of 
animal  experiments.  Finding  that  the  cornea  did  not 
tolerate  a  3  per  cent,  solution  of  carbolic  acid  very  well, 
and  a  5  per  cent,  solution  still  less,  except  when  'active 
irrigation  was  kept  up,  I  for  some  years  used  for  the  pre- 
liminary cleansing  of  the  conjunctival  sac  a  cold,  saturated 
salicylic-acid  solution,  and  after  the  year  1887  a  bichlorid 
solution  of  1  :  5000,  and  in  suspicious  cases,  1  :1000; 
and  I  still  adhere  to  this  method  at  the  present  time. 
It  has  also  been  my  constant  practice  to  keep  all  the  in- 
struments in  a  3  per  cent,  solution  of  carbolic  acid,  and  to 
return  them  to  this  solution  during  the  operation — that  is 
to  say,  operate  with  wet  instruments,  and  to  some  extent 
I  still  adhere  to  this  custom. 

As  Lister's  dressing,  on  account  of  its  stiffness,  was  not 
applicable  to  the  eye,  I,  from  the  beginning,  employed  the 
wet  salicylic-acid  dressing,  such  as  Horner  used  for  cases 
that  threatened  suppuration  or  had  already  developed 
suppurative  inflammation.  The  cotton  was  moistened 
with  a  cold  saturated  3  per  cent,  solution  of  salicylic  acid, 
applied  to  the  eye  and  constantly  kept  moist  by  the  addi- 
tion of  more  solution. 

Since  my  first  extraction  of  cataract  I  have  never  per- 
formed an  operation  without  first  injecting  the  lachrymal 
canal  for  the  purpose  of  ascertaining  the  possible  presence 
of  cartarrh  in  it  or  in  the  lachrymal  sac,  as  a  result  of 
more  or  less  marked  stenosis.  For  it  has  been  known  for 
the  past  thirty  years  that  the  source  of  a  purulent  infec- 
tion of  the  eye  is  often  situated  in  the  lachrymal  sac,  the 
secretion  of  which,  even  if  it  is  only  produced  in  small 
quantities,  is  usually  highly  infectious  and  has  been  the 
cause  of  many  a  rapidly  progressive  suppuration  after  an 
extraction  of  cataract — such  as  rendered  life  a  burden  to 
the  ophthalmic  surgeon  before  this  fact  was  properly 
recognized.  Whenever  I  ascertained  that  the  fluid  in- 
jected through  the  lachrymal  sac  and  the  lachrymonasal 


STERILIZATION,   ANTISEPSIS,   AND  ASEPSIS.       39 

canal  did  not  return  clear  or  failed  to  reappear,  the  condi- 
tion was  at  once  corrected  by  suitable  means,  as  will  he 
described  more  in  detail  later  on. 

This  antiseptic  precaution  exercised  a  favorable  influ- 
ence not  only  on  the  percentage  of  failures,  but  also  on 
the  subsequent  course  of  the  case,  by  bringing  about  a 
simple  and  uninterrupted  recovery.  Iritis  and  slowly 
progressive  cyclitis  occurred  less  frequently  after  opera- 
tions for  cataract  and  iridectomy.  The  failure-  on  account 
of  suppuration  in  my  first  -cries  of  400  cases  for  cataract, 
collected  by  Dr.  Arnold,  were  reduced  to  1  case,  or  0.25 
per  cent.,  and  in  my  first  540  operations  for  cataract 
(including  all  of  them)  to  0.37  per  cent,  of  failures  from 
suppuration. 

These  favorable  figures  were  quite  evidently  due  to  the 
antiseptic  precautions  ;  but  it  seemed  desirable  to  de- 
termine this  point  more  accurately  and  at  the  same  time 
to  find  out  why  the  recovery  is  occasionally  unfavorable. 

When  I  undertook  this  task  with  my  assistants  and 
students  Hildebrandt,  Bernheim,  and  Marthen,  the  ques- 
tion was  anything  but  clear.  Schmidt-Rimpler.  Sattler, 
Weeks,  and  others  had  shown  that  pathogenic  microbes 
are  often  found  in  the  conjunctival  sac.  especially  in  eyes 
suffering  from  purulent  catarrh  of  the  lachrymal  sac.  or 
catarrh  of  the  conjunctiva.  They  had  also  shown  how 
and  with  what  materials  the  antiseptic  precautions  which 
are  thereby  rendered  necessary  can  be  carried  out  in  the 
eve.  The  investigation-  of  Gavet,  however,  show  that  in 
spite  of  thorough  irrigation  of  the  conjunctival  sac  with  a 
bichlorid  solution  of  1  r6000  and  with  a  saturated  boric- 
acid  solution,  a  quantity  of  microbes  are  found  when  a 
culture  is  taken  immediately  before  an  operation  for 
cataract.  But  even  those  cases  in  which  such  a  culture 
was  found  to  be  positive  and  in  which  living  cocci  were 
still  present,  in  spite  of  the  previously  described  irrigation, 
very  often  made  an  uninterrupted  recovery.  On  the  other 
hand,  Sattler  and  E.  Meyer  read  a  paper  before  the 
Seventh  International  Ophthal mological  Congress  in  Hei- 


40  GENERAL  CONSIDERATIONS. 

delberg,  in  which  they  asserted  that  they  had  sterilized 
the  conjunctival  sac  by  antiseptic  measures,  although 
Chibret  on  the  same  occasion  stated  that  he  could  not 
report  a  similar  result. 

It  seemed  to  me,  therefore,  most  important  to  determine, 
by  taking  careful  cultures  (most  of  which  I  took  myself), 
the  effect  of  the  various  antiseptic  procedures  that  are 
possible  in  the  eye,  and  the  quantity  and  variety  of  the 
micro-organisms  before  and  after  the  cleansing,  both  in 
the  conjunctival  sac  and  on  the  edges  of  the  lids.  A  con- 
siderable number  of  such  cultures  were  thus  taken  from 
human  eyes  which  had  first  been  infected  by  the  introduc- 
tion into  the  conjunctival  sac  of  virulent  Staphylococcus 
pyogenes  aureus.  Attempts  were  made  with  all  kinds  of 
antiseptic  procedures  to  remove  these  cocci.  Most  of  the 
investigations  were  made  by  taking  cultures  before  and 
after  operations  for  cataract.  At  the  same  time  the  effect 
of  the  antiseptic  procedures  was  controlled  qualitatively — 
i.  e.,  by  counting  the  cultures  which  had  never  been  done 
before.  The  astonishing  fact  was  revealed  that  it  was 
impossible,  with  any  of  the  antiseptic  methods  known  at 
that  time  and  permissible  in  the  eye,  to  render  the  con- 
junctival sac  or  the  edges  of  the  lids  free  from  germs. 
The  best  result  obtained,  and  not  even  that  in  all  cases, 
was  a  diminution  in  the  number  of  germs  and  sometimes 
a  less  perfect  growth  after  the  cleansing.  Bernheim  found 
that  mere  mechanical  cleansing  by  rubbing  and  washing 
with  physiologic  sterile  salt  solution,  for  example,  was  fol- 
lowed by  a  considerable  diminution  in  the  number  of 
germs;  and  if  the  original  number  of  germs  was  small, 
these  measures  were  quite  sufficient  to  bring  about  an 
approximate  freedom  from  germs.  An  important  result 
of  our  investigation  was  to  show  that  the  edges  of  the 
lids — as  I  had  expected — play  a  very  great  part  in  the 
pollution  of  the  eye  with  microbes ;  for  the  latter  are 
often  found  in  that  region,  and  from  there  may  at  any 
time  enter  the  conjunctival  sac.  As  the  palpebral  margins, 
owing  to  their  numerous  glands  and  their  cilia,  are  even 


STERILIZATION,   ANTISEPSIS,   AND  ASEPSIS.       41 

more  difficult  to  cleanse  than  the  conjunctival  sac,  it  is 
easier  to  understand  that  the  latter  may  be  constantly 
reinfected  from  the  edges  of  the  lids.  In  addition, 
Marthen's  investigations  showed  that  the  dressing,  by 
interfering  with  the  normal  movement  of  the  lids  and 
producing  a  uniform  heat,  tends  to  increase  the  number 
of  germs ;  but  the  increase  was  less  marked  when  the 
dressing  was  kept  moistened  with  a  bichlorid  solution  of 
1  :  5000. 

Bernheim,  and  later  Marthen,  also  established  the  im- 
portant fact,  which  was  not  known  at  that  time  and  has 
since  been  confirmed  by  Bach,  Helleberg,  and  others,  that 
the  lachrymal  fluid  possesses  a  certain  bactericidal  quality 
which,  although  not  very  powerful,  yet  makes  itself  dis- 
tinctly felt  in  the  presence  of  not  too  great  a  number  of 
microbes,  even  if  they  consist  of  Staphylococcus  pyogenes 
aureus.  This  action  of  the  tears  is  no  doubt  largely  re- 
sponsible for  the  fact  that  wounds  of  the  eyes  very  often 
heal  kindly,  even  without  any  antiseptic  treatment. 

Similar  results  showing  the  insufficiency  of  antiseptic 
procedures  on  the  eye  were  obtained  by  Franke,  Bach, 
Dalen,  and  many  others  who  investigated  this  matter. 
The  two  last-named  authors  found  that  as  much  could  be 
accomplished  with  mere  mechanical  cleansing  with  physio- 
logic salt  solution  as  by  the  use  of  bichlorid  and  other 
substances,  and  ultimately  Bach  pronounced  the  former 
procedure  the  most  effective  for  the  purpose  of  obtaining 
relative  freedom  from  germs,  although  Franke  does  not 
agree  with  him. 

It  appears,  therefore,  from  these  important  investiga- 
tions that  with  the  methods  of  cleansing  at  present  in 
vogue  we  are  unable,  in  operations  on  the  eye,  to  sterilize 
the  operative  field  sufficiently  to  be  able  to  count  on  a 
smooth  recovery.  Nevertheless,  scrupulous  cleansing,  as 
our  investigations  also  showed  us,  diminishes  the  number 
of  germs  and  sometimes  reduce  it  to  zero.  On  the  other 
hand,  the  dressing  may  again  increase  the  number  of 
microbes  on  the  palpebral  margins  and  in  the  conjunctival 


42  GENERAL  CONSIDERATIONS. 

sac  by  limiting  the  movement  of  the  lids  and  maintaining 
a  uniform  heat,  which  is  favorable  for  the  growth  of 
micro-organisms — that  is  to  say,  by  furnishing  an  undis- 
turbed incubator.  The  closure  of  the  lids  hastens  the 
flow  of  tears,  and  with  them  any  germs  that  are  present 
in  the  conjunctival  sac  are  washed  out  through  the  lach- 
rymonasal  duct  and  thus  prevent  the  undisturbed  stagna- 
tion of  the  discharges  from  the  wound  and  of  the  lach- 
rymal fluid,  which  is  so  favorable  for  the  growth  of 
bacteria. 

Hence,  even  if  the  operative  field  is  carefully  washed 
off'  and  rubbed  oif  before,  and  again  washed  off  after  the 
operation,  so  as,  in  a  favorable  case,  to  reduce  the  germs 
to  a  minimum  by  these  measures,  their  number  may  again 
become  quite  considerable  after  two  or  three  days,  and 
there  is,  therefore,  always  danger  of  secondary  infection 
of  the  wound. 

It  should  follow  that  no  dressing  should  be  used  and 
that  the  eyelids  should  be  allowed  as  much  freedom  of 
movement  as  possible.  But  the  patients  usually  prefer  to 
keep  their  eyes  closed  at  first  because  they  find  it  more 
agreeable.  Theoretically  it  is  quite  correct,  after  one  or 
two  days  have  passed  and  the  first  irritation  of  the  wound 
has  subsided  so  that  the  eyes  can  be  opened,  to  apply  a 
wire-screen  dressing,  to  reassure  both  the  patient  and  the 
physician  that  the  eye  will  not  be  inadvertently  touched 
with  the  finger ;  but  my  patients,  as  a  rule,  prefer  the 
dressing,  as  they  find  the  wire  screen  unpleasant. 

Many  operators  have  adopted  this  "  open  treatment  of 
wounds" — as  it  has  been  incorrectly  called — and  have 
recommended  it  warmly  ;  but  the  expression  is  a  bad  one, 
and  here  again  the  eye  presents  conditions  which  are  quite 
different  from  those  which  obtain  in  other  regions  of  the 
body.  For  even  if  no  dressing  is  used,  it  does  not  by  any 
means  insure  an  "open  treatment  of  the  wound."  In 
most  of  the  operative  wounds  that  are  here  under  consid- 
eration the  lids  immediately  close  over  the  wound  and 
thus  furnish  the  first  suitable  covering. 


STERILIZATION,   ANTISEPSIS,   AM)  ASEPSIS.       43 

Further,  it  may  be  said  that  the  more  constantly  this 
natural  covering  is  left  in  place  during  the  first  few  days, 
the  less  will  the  closure  of  the  wound  be  disturbed  ;  and 
this  brings  us  to  what  is,  in  my  opinion,  the  most  impor- 
tant principle  in  the  treatment  of  wounds  of  the  eye. 
Primary  union  of  the  wound  in  as  short  a  time  as  possible 
is  the  thing,  above  all  others,  to  be  aimed  at,  in  order  to 
insure  freedom  from  infection  during  the  healing  ;  for  it 
offers  the  best  protection  against  the  invasion  of  patho- 
genic germs.  This  axiom  is  by  no  means  contradicted  by 
the  fact  that  the  eye  after  an  operation  for  cataract,  when 
the  wound  fails  to  close  after  several  days  and  the  anterior 
chamber  is  therefore  obliterated,  is  for  that  very  reason 
almost  absolutely  protected  against  purulent  infection  of 
the  wound.  The  latter  may,  however,  occur  immediately 
if  the  anterior  chamber  is  restored  or,  in  other  words,  the 
wound  finally  closes.  The  fact  that  it  does  not  occur 
before  is  probably  due  to  the  flow  of  aqueous  humor,  by 
which  the  wound  is  constantly  bathed  ;  although,  as  the 
investigations  of  Marthen,  Bach,  and  others  have  shown, 
the  fluid  possesses  no  germicidal  power.  When  the  wound 
is  slow  to  close  in  this  way,  irritation  and  inflammation  in 
the  anterior  chamber  are  often  observed  secondarily.  It 
is  also  important  to  prevent  with  every  means  at  our  dis- 
posal the  reopening  of  the  wound  by  mechanical  influences 
so  long  as  the  wound  can  be  spread  open — that  is  to  say, 
has  not  sufficiently  healed.  Whenever  prompt  primary 
union  of  the  wound  is  achieved  and  maintained,  the  con- 
junctival sac  may  contain  virulent  bacteria  without  neces- 
sarily causing  infection  of  the  wound. 

Bearing  these  points  in  mind,  the  operator  will,  first  of 
all,  in  every  case  keep  the  eye  that  has  been  operated  upon 
as  quiet  as  possible  for  twenty-four  to  forty-eight  hours  by 
means  of  a  dressing  that  will  take  up  the  lachrymal  fluid, 
so  that  the  dangerous  attempt  to  wipe  the  eye  will  be  ren- 
dered not  only  unnecessary,  but  will  be  absolutely  im- 
possible. In  the  second  place,  it  will  be  necessary  to  pro- 
tect eyes  that  have  been  operated  upon  against  a  blow  or 


44  GENERAL  CONSIDERATIONS. 

against  rubbing  for  from  ten  days  to  two  weeks,  so  as  to 
guard  against  reopening  the  wound.  In  this  connection  I 
may  give  the  following  facts,  which  I  have  learned  by 
experience  :  The  time  required  for  firm  union  of  an  iridec- 
tomy wound  after  an  operation  for  cataract  or  glaucoma 
varies  in  different  individuals,  and  it  is  therefore  necessary 
to  individualize  carefully.  In  moderately  vigorous  persons, 
even  of  advanced  age,  if  the  tissues  are  in  fairly  good 
condition,  moderately  firm  closure  of  the  wound  will  have 
taken  place  in  from  eight  to  ten  days,  and  provisional 
healing  may  be  said  to  have  taken  place.  On  the  other 
hand,  debilitated  and  very  senile  individuals,  especially  if 
their  digestion  is  poor,  may  require  twice  the  time.  I 
once  had  this  most  unpleasant  experience  in  the  case  of  a 
very  old  man  who  was  so  unusually  pale  and  emaciated 
that,  when  he  closed  his  eyes,  he  looked  exactly  like  a 
corpse.  As  he  assured  me  that  he  had  had  this  appear- 
ance for  many  years  and  felt  quite  well,  and  as  he  urged 
the  procedure,  I  operated  in  spite  of  these  unfavorable 
conditions.  Recovery  was  quite  satisfactory,  and  two 
weeks  after  the  operation  I  could  determine  a  visual 
acuity  of  J  and  could  order  the  glasses.  The  dressing 
was  then  removed.  The  next  day  the  eye  was  somewhat 
reddened,  so  that  I  would  not  allow  the  patient  to  start  on 
his  homeward  journey.  The  day  after  that,  to  my  great 
consternation,  a  small  hypopyon  had  appeared  in  the  an- 
terior chamber,  and  on  careful  examination  of  the  eye  I 
found  a  very  small  piece  of  vitreous  in  the  wound,  or 
rather  in  the  scar.  On  careful  questioning,  I  found  that 
he  had  rubbed  his  eye  during  the  night  after  I  had  ex- 
amined his  eyes  and  had  felt  a  little  pain.  He  evidently 
had  reopened  the  wound  at  that  time  and  the  result  was 
that  the  eye  was  almost  lost.  Beginning  at  the  wound,  a 
partial  purulent  opacity  of  the  vitreous  developed,  and, 
after  a  very  tedious  and  painful  after-treatment,  lasting 
several  weeks,  I  finally  discharged  the  patient  with  a 
visual  acuity  of  j\. 

That  reopening  of  the  wound  on  the  sixth  to  eighth 


STERILIZATION,  ANTISEPSIS,  AND  ASEPSIS.       45 

day  after  the  operation  may  be  promptly  followed  by 
purulent  infection  of  the  wound  and  loss  of  the  eye  is 
a  matter  of  general  knowledge.  As  early  in  my  career 
as  the  time  when  [  was  assistant  to  Horner  I  saw  such 
cases  develop  on  the  eighth  day,  and  in  my  own  cases 
once  on  the  sixth  and  eighth  day  after  a  perfectly  normal 
operation. 

For  this  reason  the  eye  after  operation  should  be  care- 
fully protected  for  from  eight  to  ten  days  against  a  blow 
or  even  contact  with  the  patient's  hand,  which  is  often 
anything  but  gentle.  AVhether  this  is  accomplished  with 
a  dressing  or  with  the  wire  screen  is  immaterial.  During 
the  night  a  well-applied  dressing  will  be  most  grateful  to 
the  patient.  If  it  is  desired  to  make  it  still  more  secure, 
a  wire  screen,  after  Fuchs'  or  Snellen's  aluminium  shield 
(scale),  may  be  advantageously  inserted  in  the  bandage. 
During  the  day  a  wire  screen,  after  Fuchs',  Praun's,  or 
any  other  pattern,  by  itself  will  suffice.  Here  again  the 
individual  must  be  studied.  As  long  as  there  is  lachry- 
mation  a  little  cotton  or  gauze  should  be  kept  constantly 
on  the  eye  to  absorb  the  escaping  fluid  and  obviate  any 
wiping  or  rubbing  on  the  part  of  the  patient  and  to  pre- 
vent excoriation  of  the  lids  and  surrounding  skin.  This 
may  be  covered  with  a  wire  screen  or  a  shield,  or  merely 
with  a  little  more  cotton,  and  then  fastened  with  a  roller 
bandage.  Some  eyes  do  not  bear  a  dressing  so  well  as 
others,  because  the  edges  of  the  lids  become  red  and  the 
skin  soon  begins  to  show  excoriation,  especially  near  the 
external  canthi.  In  such  cases  it  is  particularly  advis- 
able to  use  only  a  wire  screen  for  the  first  two  days  suc- 
ceeding the  operation,  unless  there  is  lachrymation,  a  con- 
dition which  also  varies  in  different  individuals. 

Bandaging". — Aside  from  certain  modifications  and 
peculiarities,  which  will  be  discussed  more  in  detail  when 
I  come  to  speak  of  the  post-operative  treatment  of  cata- 
ract, the  best  way  to  construct  a  bandage  either  for  one  or 
for  both  eyes  is  as  follows  :  An  abundance  of  absorbent 
cotton  is  laid  on  the  eye  in  such  a  way  as  to  fill  out  the 


46  GENERAL   CONSIDERATIONS. 

depression  around  the  globe — that  is,  the  hollow  between 
the  arch  of  the  nose  and  the  eye  and  between  the  upper 
margin  of  the  eyebrow  and  the  eye,  etc.,  with  moderately 
large  flakes  of  cotton,  while  the  bulbar  prominence  is 
covered  with  a  thinner  layer,  so  as  to  obtain  a  uni- 
form padding  extending  from  3-5  cm.  behind  the 
palpebral  Assure  in  all  directions.  The  cotton  is  held 
in  place  with  a  roller  bandage  3-5  cm.  in  length  and 
5  cm.  wide,  consisting  either  of  closely  woven  cotton 
cloth  (muslin)  or  of  gauze,  with  or  without  starch. 
Starched  bandages  are  the  best  and  should  be  moistened 
before  they  are  applied,  because,  as  the  dressing  dries,  the 
turns  of  the  bandage  stick  together,  and  the  dressing, 
which  also  adheres  slightly,  is  less  apt  to  be  displaced  and 
is,  therefore,  always  firm  even  if  the  individual  turns  are 
not  drawn  tight.  In  applying  a  bandage  after  operations 
on  the  eye  pressure  must  be  avoided,  with  one  exception, 
which  will  be  mentioned  later.  The  end  of  the  bandage 
is  placed  slightly  in  front  and  below  the  patient's  ear  and 
held  in  place  either  by  the  patient  or  by  the  surgeon  him- 
self, who  fixes  it  with  one  hand  while  he  makes  the  first 
turn  of  the  bandage  with  the  other.  For  one  unpractised 
it  is  better  to  allow  the  patient  to  fix  the  bandage,  as  it 
leaves  both  hands  free  to  manipulate  the  roller. 

If  one  eye  only  is  to  be  covered — monoeulus — the  first  turn 
is  carried  upward  from  the  angle  of  the  jaw7  on  the  same 
side,  over  the  pad  of  cotton  on  the  eye,  and  the  opposite 
frontal  eminence,  around  the  head,  returning  underneath 
the  ear  or  over  the  lower  portion  of  the  ear  to  the  starting- 
point.  The  second  turn  passes  over  the  eye  at  a  some- 
what higher  point  and  touches  the  opposite  frontal  emi- 
nence at  a  point  somewhat  lower;  it  then  passes  around 
the  head,  covering  a  higher  portion  of  the  ear  or  missing 
the  ear  altogether.  The  third  turn  is  placed  almost  hori- 
zontally across  the  upper  portion  of  the  cotton  pad  and 
the  superciliary  region  of  the  other  eye — i.  e.,  it  passes 
horizontally  around  the  head.  The  fourth  turn  follows 
the  same  path  as  the  third;  and,  finally,  a  few  more  turns 


STERILIZATION,   ANTISEPSIS,   AND   ASEPSIS.       47 

of  the  bandage  are  applied,  which  again  pass  underneath 
the  ear.  These  last  turns,  which  are  drawn  tight  over 
the  lower  portion  of  the  cotton  pad  over  the  eye,  and 
cover  the  side  of  the  face,  rising  gradually  so  as  to  lie 
parallel  to  the  nasolabial  fold,  are  very  important,  as  they 
prevent  the  patient  from  getting  a  finger  underneath  the 
dressing.  Educated  as  well  as  ignorant  patients  often 
have  the  bad  trick  of  trying  to  rub  the  eye  underneath 
the  bandage  whenever  they  feel  any  itching,  a  proceeding 
which  is,  of  course,  most  dangerous. 

The  double  bandage — binoculus — which  should  be  worn 
for  from  twenty-four  to  forty-eight  hours  after  an  opera- 
tion for  cataract,  because  more  perfect  rest  is  assured  to 
the  affected  eye  by  putting  the  other  eye  at  rest  also,  is 
begun  at  the  same  point  as  the  single  bandage;  but  the 
first  turn  of  the  bandage  is  carried  from  the  forehead  to 
the  occiput,  and  forward  over  the  ear  on  the  same  side  as 
the  wounded  eye  ;  it  then  passes  over  the  frontal  emi- 
nence on  that  side  and  obliquely  upward  over  the  other 
eye,  which  has  also  been  covered  with  a  cotton  pad.  The 
bandage  is  then  carried  around  the  back  of  the  neck,  and 
back  to  the  starting-point  of  the  first  turn — L  e.,  to  the 
angle  of  the  jaw  on  the  operated  side.  A  second  turn  is 
then  carried  over  the  operated  eye,  somewhat  higher  than 
the  first,  and  passes  down  correspondingly  lower  on  the 
opposite  side  of  the  head.  This  second  turn  is  also  car- 
ried over  the  occiput,  the  ear,  and  the  frontal  eminence 
of  the  same  side,  then  down  over  the  other  eye,  and  finally 
back  again  to  the  operated  eye  by  way  of  the  back  of  the 
neck,  passing  under  the  ear  of  the  same  side,  and  so  on. 
The  double  bandage  is  firmer  than  the  single  bandage, 
because  it  covers  the  head  more  completely,  and  because 
some  of  the  turns  pass  below  the  occiput,  and  over  the 
back  of  the  neck,  so  that  there  is  no  danger  of  the  band- 
age slipping  down,  an  accident  which  must  be  particularly 
guarded  against  in  the  case  of  a  single  bandage.  When 
a  moistened-starch  bandage  is  used,  the  auricular  region 


48  GENERAL   CONSIDERATIONS. 

must  be  protected  with  cotton  to  prevent  the  turns  of  the 
bandage  from  cutting  into  the  ear  as  they  harden. 

When  a  light  single  bandage  is  desired,  as  in  summer  or  when  there 
is  not  the  same  strict  indication  for  absolute  rest  and  protection  of  the 
eye  (after-treatment),  a  loosely  knitted  bandage  30  cm.  in  length,  8  cm. 
broad  in  the  middle  and  tapering  somewhat  toward  the  extremities, 
which  is  provided  with  tapes,  may  be  recommended.  [A  comfortable 
light  dressing  may  be  composed  of  an  oval  of  sterile  gauze,  over  which 
is  placed  a  suitable  pad  of  cotton,  held  in  place  with  a  few  strips  of  sur- 
geons adhesive  plaster,  which  pass  from  above  the  brow  to  the  cheek. — 
Ed.] 

The  first  requisite  of  a  dressing  that  is  applied  after  an 
operation — and  in  fact  of  any  dressing,  with  few  excep- 
tions— is  that  it  shall  not  exert  pressure  and  still  be  firm 
enough  not  to  be  readily  displaced  by  slipping,  as  that 
would  exert  an  undesirable  pressure  on  the  eye.  Nothing 
is  more  calculated  to  delay  closure  of  the  wound  after  an 
operation  for  cataract  or  an  iridectomy  (glaucoma)  than  a 
too  tightly  applied  dressing.  The  pressure  of  such  a 
dressing  constantly  reopens  the  wound,  and  the  patient  is 
very  apt  to  try  to  overcome  the  unpleasant  sense  of  press- 
ure by  closing  the  lid  tightly,  and  thus  makes  matters 
worse.  If  the  bandage  is  too  tight,  the  tears  are  pre- 
vented from  reaching  the  palpebral  fissure,  because  the 
lids  are  pressed  tightly  together,  and  in  this  case  also  the 
patient  adds  injury  by  closing  his  eyes  still  more  firmly. 
The  tears  collect  under  the  lids,  blepharospasm  increases 
more  and  more,  and  finally  there  is  severe  pain  and,  of 
course,  injurious  pressure  on  the  wound,  and  harmful  re- 
tention of  the  secretions,  both  from  the  wound  and  from 
the  conjunctiva. 

I  therefore  agree  with  Snellen,  that  a  bad  dressing  does 
more  harm  than  good.  But  for  all  that,  I  am  far  from 
advocating  "  treatment  without  bandaging  "  ;  on  the  con- 
trary, the  surgeon  should  learn  to  apply  the  dressing  cor- 
rectly and  intelligently,  and  should  remember  that  very 
much  depends  on  the  dressing  in  the  most  important 
operations  on  the  eye.  It  is  always  best  to  entrust  the 
first  dressing  after  an  operation  for  cataract  or  glaucoma 


STERILIZATION,   ANTISEPSIS,   AND  ASEPSIS.       49 

only  to  experienced  hands ;  beginners  usually  try  to  draw 
the  bandage  too  tight. 

The  dressing  should  be  so  applied  as  to  insure  the  great- 
est possible  degree  of  rest  in  the  operative  field  without 
disturbing  the  flow  of  tears.  Hence,  certain  mechanical 
factors  which  help  to  support  the  eye  after  operation  must 
be  taken  into  account,  so  as  to  enable  the  organ  to  develop 
its  inherent  tendency  to  recover. 

This  brings  us  to  the  next  question  :  Shall  we  assist 
this  natural  healing  process  still  more  by  the  use  of  anti- 
microbic  drugs,  and  how  far  may  we  go  in  that  attempt  ? 

Modern  surgery,  as  everyone  knows,  has  developed  a 
method  of  treating  wounds  which  is  known  briefly  as  the 
aseptic  method  and  is  based  on  careful  investigations  and 
a  large  experience.  The  aseptic  method,  which  was 
evolved  from  Lister's  antiseptic  method,  is  based  on  the 
principle  that  when  no  microbes  are  present,  the  use  of 
germicidal  drugs,  such  as  carbolic  acid,  bichlorid  of  mer- 
cury, and  the  like,  must  be  avoided,  because  they  irritate 
the  tissues  unnecessarily.  The  rules  in  regard  to  antisepsis 
and  asepsis  which  must  be  observed  by  the  surgeon  are 
deduced  from  the  following  axioms,  which  are  based  on 
numerous  accurate  investigations  : 

1 .  Pathogenic  germs  do  not  enter  a  wound  through  the 
air,  as  was  believed  by  Lister,  who  under  that  impression 
enveloped  the  wound  in  a  mist  of  carbolic  acid  produced 
by  a  carbolic-acid  spray. 

2.  In  a  healthy  body  the  infection  of  the  wound  does 
not  take  place  through  the  blood-  or  lymph-channels — 
that  is,  the  infection  is  never  from  within  (endogenous). 

3.  As  a  rule,  infection  is  derived  from  the  fingers,  in- 
struments, and  dressings  with  which  the  wound  comes  in 
contact  (exogenous). 

4.  Special  care  is  required  to  see  that  the  tissue  through 
which  the  incision  is  made  is  as  free  from  germs  as  pos- 
sible. 

5.  Antiseptic  precautions  are  necessary  in  the  cleansing 
of  the  hands  of  all  those  who  have  to  do  with  the  opera- 

4 


50  GENERAL   CONSIDERATIONS. 

tion  and  with  the  care  of  the  wound,  also  in  the  washing 
of  the  instruments  and  all  other  objects  that  may  come  in 
contact  with  the  operative  field.  Finally,  the  skin  where 
the  wound  is  made  must,  of  course,  be  rendered  as  free 
from  microbes  as  possible. 

After  the  operative  field  and  everything  that  comes  in 
contact  with  it  has  thus  been  rendered  sterile,  there  is  no 
further  need  of  antiseptics — the  wound  remains  aseptic 
because  there  are  no  germs  present ;  nor  need  the  dressing 
contain  any  antiseptic  substances.  Hence,  there  is  no 
need  of  an  antiseptic  fluid  for  irrigating  purposes  during 
the  operation,  nor  of  an  antiseptic  solution  to  hold  the 
instruments  during  the  operation,  to  prevent  blood  from 
adhering  to  them  ;  sterile  water  is  all  that  is  necessary  to 
wash  the  blood  from  the  wound,  the  instruments,  and  the 
hands  of  the  operator  and  his  assistants. 

As  soon  as  the  operative  field  and  everything  that 
comes  in  contact  with  it  has  been  rendered  free  from 
germs,  asepsis  begins.  In  order  to  achieve  freedom  from 
germs  antiseptic  and  sterilizing  procedures  must  be  em- 
ployed. These  procedures  are  at  present  much  more 
effective  than  were  those  known  to  and  used  by  Lister. 
Carbolic  acid,  which  was  exclusively  used  in  his  time,  has 
been  replaced  by  bichlorid  of  mercury,  which  is  more  cer- 
tain in  its  disinfecting  action,  especially  for  the  steriliza- 
tion of  the  skin.  Detailed  investigations,  especially  by 
Schimmelbusch,  have  shown  that  the  most  certain  and 
most  rapid  method  for  sterilizing  instruments  consists 
in  boiling  them  in  water  to  which  a  little  soda  has  been 
added,  and  that  the  surest  and  most  convenient  method 
of  rendering  sponges,  pads,  bandages,  operating  gowns, 
and  the  like  sterile  is  by  means  of  steam. 

In  the  modern  aseptic  method,  therefore,  antiseptics 
such  as  carbolic  acid,  bichlorid  of  mercury,  etc.,  are  not 
allowed  to  come  in  contact  with  a  recent  wound,  so  as  not 
to  injure  the  tissues,  and  allow  them  to  institute  the 
reparatory  process  as  rapidly  as  possible.  In  this  con- 
nection I  wish  to  point  out  that  Lister  (more  so  than 


STERILIZATION,   ANTISEPSIS,  AND  ASEPSIS.       51 

many  of  his  followers  in  antisepsis)  always  used  carbolic 
acid  most  sparingly  on  the  wound  itself,  as  I  know  from 
personal  observation.  He  also  protected  the  wound  from 
the  carbolic  acid  in  the  dressing  by  means  of  a  protective 
(thin  wax  or  paraffin  cloth) ;  and  when  the  dressings  were 
changed,  he  would  wash  the  wound  very  cautiously  with 
the  carbolic-acid  solution,  and  would  even  omit  doing  so 
altogether  when  it  was  not  necessary.  For  Lister  also 
believed  in  the  time-honored  principles  of  the  English 
surgeons — to  let  the  wound  alone  as  much  as  possible,  a 
principle  which,  I  believe,  we  also  should  do  well  to 
observe. 

In  the  case  of  wounds  that  have  to  be  made  in  organs 
or  parts  of  organs  that  cannot  be  rendered  free  from 
germs,  an  entirely  different  procedure  must  be  adopted. 
This  category  includes  all  wounds  that  have  to  do  with 
mucous  membranes  exposed  to  the  external  air — i.  c,  those 
of  the  mouth  or  throat,  vagina,  rectum,  or  adjoining 
regions.  These  mucous  membranes  are  more  or  less  in- 
fected with  microbes  (some  of  which  are  frequently  patho- 
genic) and,  owing  to  their  many  folds,  are  most  difficult 
to  cleanse,  and  after  a  few  days  at  the  most  the  operative 
field  will  be  again  invaded  by  a  flora  of  bacteria.  In  such 
cases  it  is  difficult  to  achieve  a  satisfactory  recovery,  and 
the  surgeon  is  therefore  compelled  to  use  active  antiseptic 
precautions  not  only  in  the  preparation  of  the  operative 
field,  but  also  later  in  the  treatment  of  the  wound,  so  as 
to  protect  it  by  weakening  as  much  as  possible  or  even 
destroying  the  growth  and  virulence  of  the  germs  that 
have  remained.  This  must  be  done  by  means  of  anti- 
septics that  do  not  unnecessarily  irritate  the  wound  and 
its  surroundings,  especially  antiseptic  powders  such  as 
iodoform,  xeroform,  airol,  etc.,  which  are  incidentally  also 
intended  to  keep  the  wound  as  dry  as  possible  by  absorb- 
ing the  secretions — for  the  growth  of  microbes  always 
requires  moisture.  Instead  of  Lister's  carbolized  gauze, 
iodoform  gauze  and  other  like  preparations  are  therefore 
used.     The  treatment  of  such  operative  wounds  is  similar 


52  GENERAL   CONSIDERATIONS. 

to  that  of  accidental  traumatic  wounds  that  are  already, 
or  may  subsequently  become,  infected. 

How  do  all  these  things  apply  to  the  eye  ?  It  is  ob- 
vious that  the  eye  presents  conditions  similar  to  those 
which  exist  in  the  above-described  wounds  of  the  second 
category,  with  this  peculiarity  however :  that,  although 
most  eyes  do  not  harbor  any  pathogenic  germs  in  their 
palpebral  margins  and  conjunctival  sac,  other  eyes  may 
be  threatened  by  the  very  worst  and  most  virulent 
microbes  which  may  be  derived  from  the  lachrymal  sac 
or  even  from  the  palpebral  margins  and  from  the  con- 
junctival sac.  Another  feature  is  that  the  lachrymal  fluid 
possesses  an  unmistakable,  albeit  faint,  bactericidal  action. 
It  is  thus  explained  why,  on  the  one  hand,  even  a  cataract 
wound  may  heal  kindly  without  any  precautions  other 
than  cleanliness,  and,  on  the  other  hand,  the  slightest 
abrasion  of  the  cornea  in  the  presence  of  numerous  in- 
fectious germs  often  speedily  becomes  the  seat  of  a  purulent 
infection,  and  in  the  case  of  a  large  incised  wound  the 
mischief  may  run  an  uninterrupted  and  most  destructive 
course. 

If  it  were  possible,  before  beginning  an  operation  for 
cataract,  to  ascertain  positively  by  making  cultures  whether 
or  not  pathogenic,  virulent  microbes  were  present  in  the 
eye  (including  the  lachrymal  sac),  such  a  precaution  would 
be  of  the  greatest  value.  But  we  are  unable  to  determine 
this,  because  it  is  impossible  to  obtain  cultures  from  all 
the  crannies  and  recesses  in  the  conjunctival  folds  and  in 
the  glands  at  the  palpebral  margins,  and  still  less  from 
the  lachrymal  sac. 

We  therefore  always  have  to  deal  with  a  more  or  less 
hidden  foe,  because  we  never  know  whether  the  operative 
field  contains  infectious,  pathogenic  micro-organisms  or  not. 
For  these  reasons  I  am  not  in  accord  with  many  recent 
ophthalmologists,  who  seek  salvation  solely  in  "  the  strictest 
asepsis" — that  is,  sterilization  of  the  hands,  instruments, 
irrigating  fluid  for  the  wound,  sponges,  etc.,  in  the  fond 
belief  that  they  are  taking  the  same  aseptic  precautions  as 


STERILIZATION,  ANTISEPSIS,  AND  ASEPSIS.       53 

the  all-round  operator  with  sterile  wounds,  if  they  cleanse 
the  skin  surrounding  the  eye  with  warm  water  and  soap. 
Most  of  them  even  remove  the  eyebrows  and  eyelashes, 
as  a  general  surgeon  would  under  similar  circumstances. 
In  my  opinion  asepsis  in  the  eye  begins  at  best  inside  the 
capsule  of  the  globe — for  the  interior  of  the  globe  may  be 
regarded  as  free  from  germs  in  a  healthy  eye.  But  even 
here  the  operative  field  is  not  entirely  sterile,  because  the 
incision  has  to  be  entered  through  a  non-sterile  region  (the 
conjunctival  sac),  and  after  the  wound  has  been  made,  it 
is  in  communication  with  non-sterile  portions  of  the 
adnexa  of  the  globe  (lachrymal  sac,  conjunctival  and  pal- 
pebral margins).  It  is  therefore  wise,  in  my  opinion,  to 
treat  our  operative  field  as  the  general  surgeon  would  treat 
one  that  cannot  be  sterilized.  Nothing  must  be  neglected. 
First,  cleanse  it  of  microbes  as  thoroughly  as  possible 
before  the  operation  ;  and,  second,  after  the  operation, 
every  endeavor  must  be  made  to  arrest  as  much  as  pos- 
sible the  growth  of  any  germs  that  may  still  be  present. 
It  may  not  be  necessary  to  kill  the  germs ;  they  need 
only  be  weakened  to  such  an  extent  that  their  virulence 
becomes  very  slight,  so  as  to  enable  the  normal  tissues 
of  the  eye  to  carry  off  the  victory  in  the  fight  against  the 
invading  parasites,  which  is  sure  to  take  place. 

This  brings  us  to  another  important  principle  in  the 
modern  treatment  of  wounds,  and  one  that  also  plays  an 
important  part  in  the  so-called  asepsis.  In  disinfecting 
the  field  before,  and  in  cleansing  it  during  and  after  the 
operation,  for  the  purpose  of  combating  the  bacteria,  the 
importance  of  guarding  against  injuring  the  tissue-cells 
of  the  wound  by  such  antiseptic  precautions  must  always 
be  borne  in  mind,  because  by  doing  so  they  would  be 
handicapped  in  their  fight  against  the  pathogenic  germs. 

Hence,  if,  with  the  object  of  severely  injuring  or  even 
destroying  any  germs  that  may  be  present,  powerful  dis- 
infectants, such  as  strong  carbolic-acid  or  bichlorid-of- 
mercury  solutions  were  to  be  employed,  the  tissue-cells 
would  be  injured,  and  many  of  them  might  perhaps  be 


54  GENERAL   CONSIDERATIONS. 

killed.  Such  a  procedure  would  work  more  injury  than 
the  microbes.  After  two  or  three  days  the  carbolic  acid 
or  bichlorid  of  mercury  has  entirely  disappeared  from  the 
wound,  and  if  any  germs  have  escaped  destruction  they 
will  find  in  the  defenseless  tissue,  which  has  been  thus  in- 
jured, and  perhaps  in  part  destroyed,  a  most  favorable 
soil  for  their  growth  and  further  propagation. 

For  these  reasons  many  ophthalmic  surgeons  have  re- 
cently adopted  the  practice  of  using  nothing  but  sterilized 
water  or  sterile  salt  solution  for  cleansing  the  conjunctival 
sac  before  and  after  operation,  supplementing  this  with 
mechanical  cleansing,  which  some  use  more  vigorously 
than  others.  The  conjunctiva  of  the  lids,  the  fornices 
and  the  bulb,  especially  the  inner  canthus  and  the  site  of 
the  incision,  are  cautiously  wiped  off,  first  with  sterile 
pledgets  and  then  with  pledgets  saturated  with  the  irri- 
gating fluid. 

The  only  antibacterial  substances  that  ought  to  be  used 
in  the  wound  for  the  purpose  of  covering  them,  for  ex- 
ample, are  such  as  do  not  injure  the  tissue  and  continue 
to  remain  active  until  the  wound  is  healed.  These  indi- 
cations are  met  chiefly  by  antiseptic  powders,  which  have 
already  been  mentioned,  particularly  iodoform.  But  even 
these  powders,  when  directly  applied  to  the  membrane, 
cause  too  much  irritation  of  the  cornea,  in  which  or  at  the 
border  of  which  the  incision  in  cataract  operations  and 
iridectomy  is  made ;  the  patient  is  worried,  becomes  rest- 
less, and  this  interferes  with  rapid  closure  of  the  wound — 
which  is  so  important — and  finally  the  increased  flow  of 
tears  produced  by  the  irritation  simply  washes  away  the 
powder ;  so  that  at  best  no  benefit  has  been  derived  and 
the  patient  has  been  uselessly  worried. 

But  it  is  quite  advisable  to  apply  finely  divided  iodo- 
form powder  at  some  distance  from  the  wound  in  the 
globe,  as 

1.  At  the  inner  canthus — for  we  know  that,  owing  to 
the  proximity  of  the  lachrymal  sac,  this  part  of  the  eye 
needs  the  most  careful  disinfection. 


STERILIZATION,   ANTISEPSIS,   AND  ASEPSIS.       55 

2.  To  the  closed  lids,  because  the  palpebral  margins,  as 
investigations  in  our  clinic  have  shown,  are  also  a  special 
source  of  danger,  and  contain  many  hiding  places  for  mi- 
crobes that  are  difficult  to  reach. 

I  know  from  an  experience  of  fifteen  years  that  iodo- 
form applied  to  the  outer  can  thus  and  to  the  lids  is  neither 
irritating  nor  injurious,  and  I  confidently  recommend  its 
use  as  here  described.  This  fact  was  the  subject  of  a 
paper  that  I  published  in  1891. 

But  the  iodoform  must  be  carefully  purified  beforehand 
by  washing  it  for  a  few  days  in  a  3  or  5  per  cent,  solution 
of  carbolic  acid.  It  is  then  put  in  a  covered  dish  and 
allowed  to  dry,  in  the  incubator  or  elsewhere  ;  after  which 
it  must  be  rubbed  up  again  with  sterile  instruments, 
because  it  has  a  tendency  to  form  lumps  as  it  dries. 

Some  persons  possess  an  idiosyncrasy  for  iodoform — just  as  others 
are  abnormally  susceptible  to  bichlorid  of  mercury — and  develop  a 
most  unpleasant  eczema  :  the  phenomenon  is  rare,  but  is  occasionally 
observed.  A  colleague  of  mine  told  me  that  he  once  saw  an  eye  lost 
from  suppuration  following  an  eczema  which  developed  as  the  result  of 
the  use  of  iodoform  after  an  operation  for  cataract.  Personally  I  have 
so  far  never  seen  this  sensitiveness  to  iodoform. 

Hence,  even  if  we  are  unable  to  achieve  complete  ster- 
ilization of  the  operative  field  in  the  eye,  as  the  investi- 
gations in  our  clinic  appear  to  show7,  we  should  neverthe- 
less, in  my  opinion,  make  every  effort  to  accomplish  that 
end  as  nearly  as  possible,  and  to  render  any  microbes  that 
may  have  remained  in  the  wound  as  nearly  harmless  as 
possible. 

The  first  logical  conclusion  to  be  deduced  from  our  in- 
vestigation is  that  the  lashes  and  eyebrows  must  be  re- 
moved before  an  operation  for  cataract.  The  lashes  should 
be  cut  off  with  the  scissors  and  the  eyebrows  shaved.  I 
have  learned  by  many  years'  experience  that  the  unpleas- 
ant results,  such  as  itching  as  the  hair  grows  in,  do  not, 
as  I  had  at  first  feared,  occur.  On  the  other  hand,  it  is  at 
once  noticeable  in  the  case  of  such  patients  how  much  more 
easily  and  better  the  cleansing  of  the  edges  of  the  lids, 


56  GENERAL  CONSIDERATIONS. 

which  is  such  an  important  procedure,  can  be  performed, 
especially  when  the  dressing  is  changed  after  the  opera- 
tion, because  the  secretion  does  not  adhere  to  the  eye- 
lashes. Anyone  who  has  carefully  observed  his  cataract 
patients  during  the  summer  can  not  have  failed  to  notice 
that  many  of  them,  especially  peasants — who  often  cover 
themselves  up  to  the  chin  in  spite  of  the  heat — and  obese 
individuals,  sweat  so  profusely  that  the  perspiration  rolls 
down  over  the  forehead.  It  is  evident,  therefore,  that 
from  the  regions  of  the  eyebrows,  which  in  many  cases 
can  not  be  cleansed  without  shaving,  microbes  may  be 
carried  down  to  the  palpebral  fissure  by  the  perspiration 
and  may  from  there  reach  the  conjunctival  sac,  especially 
if  the  eye  is  not  bandaged.  This  is  another  reason  for 
applying  a  bandage  with  a  cotton  pad  during  the  first 
days  after  the  operation,  even  when  the  eyebrows  have 
been  shaved. 

Trimming  the  eyelashes  and  shaving  the  eyebrows  be- 
fore operations  for  cataract  is  not  nearly  as  universal 
a  proceeding  as  it  ought  to  be.  On  the  other  hand, 
forcible  epilation  of  all  the  cilia  before  the  operation,  as 
recommended  by  Hjort,  is,  in  my  estimation,  too  heroic  a 
procedure.  It  is  a  cruel  practice  and  not  only  unneces- 
sary, but  even  injurious,  owing  to  the  irritation  of  the 
palpebral  margins  which  follows.  If  for  some  reason 
there  is  an  objection  to  cutting  off  the  cilia,  they  should 
at  least  be  freed  from  the  germs  with  a  cotton  pledget 
dipped  in  benzine,  a  procedure  which,  according  to  von 
Pflugk,  renders  them  free  from  germs. 

Before  every  operation  for  cataract  and  before  other 
operations,  at  least  when  suspicious  symptoms  such  as 
epiphora,  conjunctivitis,  and  blepharitis  are  present,  the 
lachrymal  passages  should  be  tested  not  only  to  determine 
whether  they  are  patulous,  but  whether  they  are  normal  as 
well.  In  some  cases  fluid  that  is  injected  through  the 
lower  canaliculus  flows  freely  from  the  nasal  orifice  on  the 
corresponding  side,  but  the  fluid  is  turbid  from  catarrh 
of  the  lachrymal  sac  or  the  lachrymonasal  duct.     In  order 


STERILIZATION,   ANTISEPSIS,   AND  ASEPSIS.       57 

to  determine  whether  the  injected  fluid,  which  should  be 
a  bichlorid-of-mercury  solution  of  1  :  5000,  is  turbid  or 
not,  it  is  best  to  collect  it  in  a  clean  black  receptacle,  as, 
for  example,  one  made  of  hard  rubber.  In  this  way  the 
faintest  suspicion  of  cloudiness  can  be  detected.  I  con- 
sider this  a  very  important  point.  If  the  fluid  is  not 
clear,  the  lachrymal  apparatus  should  first  be  treated  for 
a  time  with  irrigation,  using  preferably  a  freshly  prepared 
1-2  per  cent,  protargol  solution,  which  is  to  be  injected 
once  a  day  for  several  days.  [For  this  purpose  a  20  per 
cent,  solution  of  argyrol  is  most  efficient. — Ed.] 

It  is  needless  to  say  that  the  syringe — which  ought 
always  to  be  of  glass — must  be  carefully  sterilized  before 
it  is  used  for  these  diagnostic  or  prophylactic  injections. 
The  sterilizing  is  done  by  placing  the  glass  syringe,  with 
the  can u la,  in  a  bichlorid  solution  of  1  :  1000  for  a  few 
minutes,  or  by  boiling.  If  the  patient  is  sensitive,  a  few 
drops  of  a  2-5  per  cent,  solution  of  cocain  are  injected 
into  the  lachrymal  sac  as  a  preliminary  measure.  The 
lower  canaliculus,  which  is  a  little  wider  and  more  con- 
veniently situated,  is  for  obvious  reasons  selected  for  mak- 
ing the  injections  ;  it  must  be  somewhat  dilated  with  a 
conical  probe,  to  facilitate  the  introduction  of  the  delicate 
Anel  syringe.  Both  the  probe  and  the  syringe  are  intro- 
duced into  the  canaliculus  at  first  vertically  and  then 
horizontally,  as  the  canal  at  first  runs  vertically  from  the 
lachrymal  punctum  ;  unless  this  precaution  is  observed, 
there  is  danger  of  making  a  false  passage.  The  entire 
procedure  must  be  executed  with  a  light  hand  and  with 
great  caution.  At  the  same  time  the  operator  should 
observe  how  the  patient  reacts  to  the  interference,  as  it 
will  guide  his  actions  later  during  the  operation.  If  the 
patient  takes  the  injection  quietly,  it  is  most  probable  that 
he  will  be  equally  quiet  during  the  operation. 

If  marked  or  complete  stenosis  of  the  lachrymonasal 
duct  be  discovered,  the  condition  may  be  treated  by  intro- 
ducing the  probe  or  by  extirpating  the  lachrymal  sac  if  it 
is  secreting.     The  latter  procedure  is  absolutely  necessary 


58  GENERAL   CONSIDERATIONS. 

if  there  is  much  secretion.  If  the  catarrh  is  slight,  it  is 
not  absolutely  necessary  to  extirpate  the  sac,  a  procedure 
to  which  patients  are  very  apt  to  refuse  their  consent.  It 
may  be  treated  for  from  three  to  five  days  with  injections 
of  protargol  [or  argyrol — Ed.],  and  finally  with  a  1  :  1000 
bichlorid  solution,  after  which  the  canaliculi  are  tem- 
porarily closed.  This  procedure,  which  I  have  practised 
for  the  past  fifteen  years,  and  recommended  in  1891,  I 
have  so  far  found  uniformly  successful;  it  is  also  employed 
by  Snellen,  who  speaks  of  it  in  his  recently  published 
Operationslehre.  The  galvanocautery  is  compressed  to 
form  a  point  and  introduced  a  few  millimeters  into  the 
upper  and  lower  canaliculus,  and  the  current  closed.  The 
latter  need  be  strong  enough  only  to  produce  a  faint  red 
heat.  The  effect  of  this  cauterization  is  to  cause  tem- 
porary adhesion  of  the  canaliculi,  which  prevents  any 
secretion  that  may  be  present  in  the  lachrymal  sac  from 
entering  the  conjunctiva.  If  any  subsequent  treatment  is 
to  be  employed,  the  canaliculus  can  be  reopened  with  a 
conical  probe.  When  one  of  the  canaliculi  has  already 
been  slit,  I  nevertheless  cauterize  it  as  wTell  as  possible 
and  introduce  one  of  my  iodoform  pencils.  I  may  say  in 
support  of  this  procedure  that  I  have  so  far  never  seen 
any  case,  in  which  an  operation  for  cataract  had  to  be 
performed  in  the  presence  of  an  existing  dacryostenosis, 
give  trouble  during  its  subsequent  course.  It  is  true  that 
I  always  make  it  a  practice  in  these  cases  to  fill  the  inner 
canthus  with  iodoform. 

In  1890  Eversbusch  advised  ligation  of  the  canaliculi 
with  catgut  to  render  them  impervious.  [Ligation  of  the 
canaliculi  is  also  advised  by  Buller,  and  represents  an 
excellent  practice  in  suitable  cases. — Ed.] 

The  edges  of  the  eyelids,  in  my  estimation,  may  be  as 
great  a  source  of  danger  as  the  lachrymal  sac,  especially 
when  they  are  inflamed.  It  is  true  that  they  do  not  come 
in  direct  contact  with  cataract  wounds  nor  with  the  iri- 
dectomy wound  in  glaucoma,  if  the  customary  upper  in- 
cision is  employed,  and  the  surgeon  avoids  using  the  lower 


STERILIZATION,   AST  I  SEPSIS,   AND  ASEPSIS.       59 

lid  to  turn  out  the  remains  of  the  cataract.  Nevertheless 
the  investigations  of  Bernheim,  as  I  have  already  stated, 
have  shown  the  importance  from  a  prognostic  point  of 
view  of  the  relation  existing  between  the  palpebral  mar- 
gins and  the  conjunctival  sac — for  micro-organisms  readily 
make  their  way  from  the  lids  to  the  conjunctiva  and  may, 
of  course,  very  easily  spread  between  the  lids  and  the 
bulb. 

It  is  therefore  most  advisable  to  pay  the  closest  atten- 
tion to  the  palpebral  margins  in  preparing  the  eye  for 
operation,  especially  for  cataract,  and  our  present  anti- 
septic and  aseptic  methods  are  anything  but  satisfactory 
when  applied  to  these  structures.  The  possibility  of 
cleansing  the  palpebral  margins  with  ichthyol  will  be 
referred  to  again  in  connection  with  the  postoperative 
treatment  of  cataract. 

In  order  to  guard  as  much  as  possible  against  failures, 
rigorous  precautions  must  be  adopted  to  avoid  pollution 
of  the  operative  field  during  and  after  the  operation.  In 
this  respect  the  following  rules  should  be  observed : 

1.  As  in  performing  iridectomy  and  operations  for  cata- 
ract it  is  usually  necessary  to  talk  in  order  to  give  the 
patient  directions  or  to  quiet  him,  or  even  to  scold  him 
when  he  loses  his  self-control,  it  is  not  too  much  to  say 
that  the  operation  for  cataract  is  the  one  which  of  all 
operations  performed  on  man  most  requires  precaution 
against  salivary  infection,  especially  as  the  operation  is 
very  often  performed  on  people  who  are  old  and  hard-of- 
hearing.  For  this  reason  the  wearing  of  a  mouth-bandage 
or  mouth-mask  is  distinctly  indicated  in  these  operations. 

For  years  before  I  adopted  the  mouth-bandage  I  was  in  the  habit  of 
having  a  plate  of  glass  held  above  the  operative  field,  especially  when 
I  was  operating  before  students  and  wished  to  make  explanatory  re- 
marks ;  but  the  mouth-bandage  is  more  convenient. 

[The  following  interesting  facts  in  this  connection  are 
quoted  from  an  editorial  in  the  Journal  of  the  American 
ATerJieal  Association :  "  It  has  long  been  recognized  that 
saliva    is   an    extremely  dangerous  medium  of  infection, 


60  GENERAL   CONSIDERATIONS. 

but  it  has  remained  for  de  Leon  to  demonstrate  just 
how  frequently  it  may  be  responsible  for  the  instances 
of  so-called  unavoidable  surgical  infection.  From  a 
long  series  of  careful  and  well-controlled  experiments, 
he  has  obtained  some  very  striking  results.  It  was 
found  that  on  the  average  about  two  hundred  words 
were  spoken  by  the  operator  alone  in  an  ordinary  opera- 
tion. On  an  average,  in  each  drop  of  saliva  occur 
4375  bacteria,  and  in  the  duration  of  an  average  opera- 
tion 250,000  organisms  may  gain  direct  entrance  to  the 
wound.  Among  these,  virulent  organisms  are  constantly 
present,  streptococci,  diplococci,  and  staphylococci,  in 
order  of  their  frequency.  To  avoid  this  source  of  con- 
tamination, de  Leon  devised  a  simple  mouth-mask  which 
is  efficacious  and  not  burdensome  and  does  not  interfere 
with  distinct  articulation.  Some  bacteria  were  found 
to  penetrate  a  gauze  mouth-covering,  though  the  num- 
ber was  materially  reduced.  If  experience  has  shown 
that  wounds  are  usually  capable  of  withstanding  a  large 
number  of  bacteria,  it  has  also  demonstrated  that  under 
suitable  conditions  a  few  bacteria  may  give  rise  to  serious 
and  even  fatal  infection.  Surgeons  who  have  good  per- 
sonal technic  and  equally  careful  assistants  should  con- 
sider this  fruitful  source  of  infection,  particularly  where 
teaching  makes  more  continuous  and  louder  talking  a 
necessity/' — Ed.] 

2.  In  handling  the  instruments  immediately  before  and 
after  the  operation  great  care  is  necessary  to  avoid  bring- 
ing them  in  contact  with  any  unclean  object.  This  pre- 
caution is  particularly  important  as  regards  knives  and 
needles  which  are  to  be  introduced  within  the  eye.  It  has 
long  been  a  matter  of  experience,  and  the  accident  still 
occurs,  although  less  frequently  than  formerly,  that  an 
operation  of  this  kind,  especially  for  cataract  or  one  of  a 
secondary  nature,  is  followed  by  an  intense  purulent  in- 
fection or  a  subacute  inflammation,  although  no  cause  for 
the  accident  can  be  found.  The  catastrophy  falls  like 
"  a  bolt  from  the  blue,"  and  not  only  the  affected  eye  is 


STERILIZATION,   ANTISEPSIS,   AM)  ASEPSIS.       61 

ruined,  but  the  health  of  the  other  eve  is  also  endangered, 
and  sometimes  blindness  results. 

Fig.  1  shows  how  an  infection  of  this  kind  may  take 
place.  The  method  of  holding  the  cataract  knife  or  cata- 
ract needle  which  is  shown  in  the  picture,  and  which  is  to 
be  absolutely  condemned,  is  one  that  the  operator  is  quite 
likely  to  be  guilty  of  if  he  finds  something  to  correct  in 
the  position  of  the  eye  speculum  at  the  beginning  of  the 
operation  ;  as,  for  example,  drawing  the  lids  further  apart. 
When  the  instrument  is  held  in  this  way,  the  point  is 
very  apt  to  come  in  contact  with  some  object  outside  of 
the  sterile  field  and  become  polluted  without  the  surgeon 
becoming  aware  of  the  fact.  I  myself  once  had  this  ex- 
perience— that  is,  I  touched  something  with  the  instru- 
ment and  fortunately  felt  it.  It  called  my  attention  to 
the  danger  of  handling  instruments  in  this  careless  way. 
The  surgeon  should  break  himself  of  the  bad  habit  of 
holding  any  cutting  or  pointed  instrument  in  this  faulty 
manner,  which  probably  has  its  origin  in  the  dissecting 
room. 

3.  In  order  to  guard  as  much  as  possible  against  such 
pollution  of  the  instruments  the  entire  area  surrounding 
the  operative  field  should  be  covered  with  sterile  gauze, 
leaving  only  the  eye  exposed  (see  Plates  2,  4,  7).  The 
gauze  is  first  wrung  out  of  a  1  :  1000  bichlorid  solution, 
to  make  it  adhere  to  the  skin. 

4.  There  is  no  doubt  that  infection  may  also  be  caused 
by  the  use  of  imperfectly  sterilized  drops  introduced  into 
the  eye  before  or  after  the  operation.  It  is  needless  to 
say  that  any  fluid  used  as  a  colly rium  must  be  carefully 
sterilized  before  being  used.  This  is  best  accomplished 
by  boiling,  because  the  addition  of  bichlorid  of  mercury 
(boric  acid  is  absolutely  useless)  injures  the  solution, 
especially  pilocarpin,  and  produces  unnecessary  irritation 
in  many  eyes.  It  is  also  important  to  make  sure  that  the 
sterilized  solutions  remain  free  from  germs  by  having 
them  boiled  again  from  time  to  time ;  for  there  is  no 
doubt  that  secondary  pollution  of  sterilized  collyria  not 


62  GENERAL   CONSIDERATIONS. 

infrequently  takes  plaee.  Sidler-Huguenin  succeeded  in 
finding  microbes  quite  frequently  in  solutions  that  we 
had  used  for  some  time,  and  these  microbes  consisted  not 
only  of  sarcinse  and  mold  fungi,  but  also  of  streptococci 
and  staphylococci  which  were  found  to  be  pathogenic. 
[Some  years  ago  Dr.  E.  A.  de  Schweinitz  and  the 
editor  made  an  elaborate  bacteriologic  examination  of 
the  pipets  and  collyria  taken  from  a  treatment  case  which 
had  been  used  in  ophthalmic  practice  for  some  time,  and 
found  in  the  fluids  the  micrococcus  aquatilis,  the  bacillus 
liquefaeiens,  the  proteus  vulgaris,  the  micrococcus  pro- 
digeosus,  the  bacillus  implexus,  and  aspergillns  glaucus, 
as  well  as  staphylococci  and  streptococci.  The  proteus 
vulgaris,  the  micrococcus  prodigeosus,  and  the  bacillus 
implexus  obtained  from  these  solutions  introduced  into 
the  anterior  chamber  of  rabbits  produced  a  violent  in- 
flammation of  the  iris  and  anterior  portion  of  the  eye. 
Inoculations  with  the  other  organisms,  except  staphy- 
lococci and  streptococci,  were  negative. — Ed.]  It  is 
therefore  absolutely  necessary  that  the  solutions  used  at 
an  operation  have  been  recently  boiled,  and  during  the 
postoperative  treatment  it  is  also  necessary  to  use  sterile 
solutions.  This  is  not  such  a  simple  matter  as  it  would 
seem.  It  necessitates,  first  of  all,  properly  working  drop- 
ping bottles  that  can  be  boiled  with  their  contents  and  in 
which  there  is  not  much  danger  of  a  subsequent  pollution 
of  the  contents.  Stroschein,  Snellen,  and  others  have 
busied  themselves  considerably  with  the  improvement  of 
dropping  bottles.  As  Stroschein's  bottle  did  not  suit  us 
altogether,  Sidler-Huguenin  devised  one  which  presents 
certain  additional  improvements,  the  most  important  of 
which  is  the  extra  width  of  the  mouth,  so  that  in  putting 
the  pipet  back  in  the  bottle  there  is  less  danger  of  striking 
the  point  against  the  lip  or  even  the  outside  of  the  bottle, 
an  accident  that  is  apt  to  happen  with  any  dropping  bottle 
hitherto  devised.  As  the  outside  of  the  bottle  cannot  be 
kept  absolutely  clean  while  it  is  in  use,  it  is  always  pos- 
sible that  the  point  of  the  pipet  may  be  polluted   by 


61 


< ;  EN  ERA  L   COS  SID  ERA  TIOXÜ. 


coming  in  contact  with  it  and  may  thus  contaminate  the 
solution,  so  that  the  latter  very  soon  ceases  to  be  free 
from  germs. 

It  should  also  be  impossible  for  the  contents  of  the 
pipet  to  get  up  into  the  bulb  when  the  former  is  accident- 
ally reversed,  as  very  often  happens  with  the  attendants, 
and  is  very  difficult  to  prevent.  This  requisite  is  also 
fully  satisfied  by  Sidler's  dropping  bottle.  The  bulb  is 
provided  with  a  spiral  tube  (see  Fig. 
2),  so  that  the  fluid  can  not  get  up 
into  it  from  the  dropper,  no  matter 
how  often  it  is  held  upside  down. 

These  bottles  may  be  sterilized,  a 
large  number  at  a  time,  with  steam, 
as,  for  example,  in  Budenberg's  ap- 
paratus ;  or  the  bottle  may  be  placed 
over  a  flame,  with  a  piece  of  wire 
screen  to  prevent  cracking,  and  used 
for  boiling  the  contained  solution. 
In  either  case  a  small  glass  rod  is 
placed  between  the  bottle  and  the 
pipet  to  prevent  the  latter  from  act- 
ing as  a  stopper. 

It  is  not  well  to  boil  our  alkaloid 
solution  too  often.  In  the  case  of 
cocain  the  following  points,  which 
have  been  determined  by  the  careful 
investigations  of  Sidler-Hugnenin, 
must  be  borne  in  mind :  A  cocain 
solution  of  more  than  1  per  cent,,  if  sterilized  several  times 
for  twenty  minutes  with  steam,  loses  part  of  its  anesthetic 
action,  and  a  greater  number  of  drops  are  therefore  re- 
quired to  produce  the  same  effect,  On  the  other  hand, 
when  a  3  per  cent,  solution  of  cocain  is  boiled  for  a  short 
time,  even  if  the  procedure  is  repeated  several  times,  the 
anesthetizing  strength  is  not  impaired.  A  weak  solution 
is  injured  more  by  boiling  than  is  a  strong  one.  As  we 
do  not  possess  any  antiseptic  suitable  for  addition  to  our 


Fig.  2.— Sidler's  dropping 
bottle. 


STERILIZATION,   ANTISEPSIS,   AND  ASEPSIS.       65 

eye  solutions  in  all  cases,  a  practitioner  will  do  well  to 
keep  an  alcoholic  stock  solution  on  hand  and  prepare 
small  quantities  of  Cocain  and  atropin  solutions  as  he 
needs  them,  while  in  hospitals,  and  whenever  larger  quan- 
tities are  used,  watery  solutions  are  preferable ;  but  they 
must  be  sterilized  at  regular  intervals.  [The  best  plan  is 
to  have  all  solutions  used  in  eye  operations  prepared  and 
properly  sterilized  immediately  before  the  operations,  and 
not  again  use  these  solutions  in  subsequent  operations. — 
Ed.] 

5.  To  make  absolutely  sure  that  accidental  infection  of 
the  operative  field  has  not  taken  place  through  sponges, 
gauze,  dressing  materials,  sterilized  water  or  sterilized 
salt  solution,  the  surgeon  must  see  to  it  that  all  these 
objects  are  really  sterilized.  It  is  to  be  remembered  that 
sponges,  gauze,  and  cotton  for  dressings,  while  they  may 
be  rendered  sterile  as  regards  pathogenic  micro-organisms 
by  one  hours'  exposure  to  steam  not  under  pressure,  will 
not  be  sterile  as  regards  tetanus  spores  and  the  spores  of 
mbtilis,  which  are  only  killed  by  a  short  exposure  to  steam 
under  pressure  at  140°  C.  (284°  F.). 

AVater  and  saline  solutions  may  be  regarded  as  free 
from  active  pathogenic  microbes  after  boiling  for  one-half 
hour.  To  render  them  absolutely  free  from  germs,  in- 
cluding the  spores  referred  to  above,  requires  several 
hours'  boiling.  This  is  also  true  of  intruments,  which 
are  freed  only  from  the  pathogenic  germs  by  the  degree 
of  boiling  to  which  they  are  customarily  subjected  (see 
Brunner). 

The  edge  and  point  of  an  instrument  suffer  less  when 
the  boiling  is  done  in  a  porcelain  vessel,  with  or  without 
the  addition  of  soda.  (For  this  information  I  am  in- 
debted to  Mr.  Weiss,  a  London  instrument-maker.)  It 
is  better  not  to  put  the  instruments  into  the  fluid  until 
after  the  air  has  been  driven  off  by  boiling.  [The  blades 
of  sharp  instruments  should  be  wrapped  in  absorbent 
cotton  before  they  are  boiled  ;  this  lessens  the  danger  of 
causing  their  points  and  edges  to  become  dull. — Ed.] 


66  GENERAL   CONSIDERATIONS. 

Themost  satisfactory  method  of  sterilizing  gauze,  sponges, 
and  the  cotton  used  in  the  dressing,  is  to  put  them  into  a 
moderately  large  tin  drum  with  wire  ends  which  can  be 
closed,  after  the  sterilization  is  completed,  with  a  tin  cover 
that  has  also  been  sterilized,  and  disinfect  them  in  a  large 
sterilizer  which  can  be  warmed  afterward,  so  as  to  dry 
the  materials  out  thoroughly.  If  the  operator  is  not 
quite  certain  that  the  water  or  saline  solution  which  is 
used  for  cleansing  the  conjunctival  sac  and  keeping  the 
wound  clean,  as  well  as  that  in  which  the  instruments 
are  placed,  has  been  properly  sterilized,  he  will  do 
better  to  use  a  1  :  5000  solution  of  bichlorid  of  mercury 
for  the  eye,  and  a  3  per  cent,  solution  of  carbolic  acid 
for  the  instruments,  unless  it  is  desired  to  use  them  dry 
after  they  have  been  boiled.  The  operator  can  always 
determine  quite  readily  whether  the  fluid  contains  bichlorid 
of  mercury  or  carbolic  acid,  as  the  former  substance  is 
recognized  by  its  taste  and  the  latter  by  its  smell.  He 
can  not,  however,  tell  whether  water  is  really  sterile,  and 
has  no  means  of  being  sure  that  he  has  not  been  given 
unsterilized  water  by  mistake. 

In  this  connection  Schirmer  relates  a  most  important  personal  ex- 
perience, which  shows  how  easily  a  mistake  may  occur  in  these  matters. 
After  he  had  operated  on  a  large  number  of  cataract  cases — about  200 — 
extending  over  a  period  of  years,  and  the  subsequent  course  had  been 
practically  normal  in  all,  a  change  suddenly  took  place.  In  every 
seventh  case,  and  later  even  more  frequently  (  in  30  per  cent,  of  the 
cases),  extraction  of  the  cataract  was  followed  in  from  five  to  twelve 
days  by  an  iridocyclitis  with  small  deposits  on  Descemet's  membrane. 
He  observed  this  same  complication  after  an  iridectomy  and  after  a 
discission.  It  is  true  that  all  the  cases,  after  appropiate  treatment,  event- 
ually ended  in  recovery  with  a  good  visual  acuity ;  but  convalescence 
lasted  from  two  to  three  weeks,  and  in  4  cases  in  which  there  had  been  a 
recurrence  of  the  inflammation  from  two  to  three  months  of  treatment 
were  required.  Schirmer  had  performed  all  these  operations  by  the 
aseptic  method,  using  antiseptics  only  for  the  hands  and  for  the  cleansing 
of  the  galley  pots,  and  a  3  per  cent,  boric-acid  solution  for  moistening 
his  cotton  sponges,  which  had  been  sterilized  with  steam.  By  a  mistake 
of  the  attendant  this  boric-acid  solution  had  not  been  prepared  ac- 
cording to  directions.  He  had  measured  out  the  correct  quantity  of 
boric  acid,  dissolved  it  in  boiling  water,  and  then  merely  diluted  it  to 
the  proper  strength  with  ordinary  well  water,  neglecting  to  boil  the 


STERILIZATION,   ANTISEPSIS,   AND  ASEPSIS.       67 

entire  solution.     As  soon  as  this  error  in  technic  had  been  corrected, 
Schirmer  had  no  more  cases  of  iritis. 

In  connection  with  the  question  of  infection  I  must 
not  neglect  to  state  an  important  principle  which  must  be 
kept  in  mind  during  operations.  It  is  a  principle  that  is 
not  always  properly  respected,  especially  by  beginners, 
and  may  be  state* I  thus  :  Operations  involving  the  open- 
ing of  the  capsule  by  incision  or  puncture  should  not,  if 
at  all  possible,  be  performed  at  short  intervals  on  the 
same  eye ;  but  only  after  the  eye  has  become  entirely  free 
from  any  symptoms  of  inflammation,  or  even  of  mere  irri- 
tation (as  evidenced  by  lacrimation  and  ciliary  redness). 
Any  fresh  operative  intervention  affecting  the  iris  and 
ciliary  body  is  particularly  dangerous  and  very  apt  to 
produce  sympathetic  disease  of  the  other  eye,  especially 
if  the  operation  involves  an  incision  at  the  corneal  margin 
— that  is,  in  the  neighborhood  of  the  ciliary  body,  and 
particularly  when  the  vitreous  comes  in  contact  with  the 
operative  wound.  Special  caution  in  this  respect  is  neces- 
sary in  those  cases  in  which  the  eye  after  an  unsuccessful 
operation  for  cataract  is  to  be  put  into  better  condition,  or 
in  cases  in  which  the  effects  of  traumatism  are  to  be  cor- 
rected before  the  eye  has  recovered  from  the  original 
operative  procedure. 

The  reasons  for  this  will  require  for  their  elucidation  a 
good  deal  of  further  investigation.  One  factor  is  obvious 
— namely,  that  in  any  injured  or  operated  eye  requiring  a 
bandage,  the  germs  frequently  multiply  in  the  course  of 
time  underneath  the  bandage ;  for  when  the  eye  has  been 
bandaged  for  some  time,  catarrh  of  the  conjunctiva  and  a 
slight  degree  of  blepharitis  are  apt  to  develop,  and  con- 
junctivitis and  blepharitis  are  always  liable  to  increase 
the  number  of  the  germs  in  the  conjunctival  sac.  If 
another  operation  is  performed  on  the  eye  while  it  is  in 
this  condition,  the  danger  of  infection  to  the  anterior 
chamber  is  very  great. 

It  is  also  probable  that  the  operative  field  often  suffers 
a   certain   degree   of   pollution    from   pathogenic   micro- 


68  GENERAL   CONSIDERATIONS. 

organisms  during  the  first  operation,  the  effects  of  which, 
however,  gradually  disappear  without  any  great  danger 
resulting,  because  the  tissues  of  the  interior  of  the  eye — 
the  anterior  chamber  and  adjoining  portions — gradually 
dispose  of  the  parasites.  Sometimes  they  are  probably 
first  covered  with  exudate  or  leukocytes  and  then  become 
more  or  less  encapsulated  and  are  thus  rendered  harmless. 
If  this  course  of  healing  is  disturbed  by  a  second  opera- 
tive intervention,  the  inflammatory  process  may  be  sud- 
denly lighted  up  again  and  become  more  severe  than 
before. 

Exceptions  to  the  important  rule  not  to  multiply  opera- 
tions in  the  same  eye  are  found  in  the  following  cases : 

1.  If  the  lens  has  been  injured,  either  purposely  or 
accidentally  (by  trauma),  and  increased  tension  occurs  as 
the  result  of  traumatic  cataract,  puncture  becomes  neces- 
sary and  may  have  to  be  repeated  if  the  tension  of  the 
eye  again  becomes  abnormally  high. 

2.  After  an  iridectomy  for  glaucoma,  if  the  effect  has 
not  been  sufficiently  marked,  a  second  iridectomy  or, 
better,  a  sclerotomy,  must  be  performed.  The  latter 
operation  may  even  be  repeated  whenever  it  seems  neces- 
sary. 

3.  If  an  operation  for  cataract  is  followed  by  a  normal 
recovery  without  any  inflammation,  so  that  the  eye  clears 
up  at  the  end  of  two  weeks,  discission  may  be  performed 
on  the  secondary  cataract,  but  with  the  utmost  caution. 
In  most  cases,  however,  it  is  well  to  wait  from  four  to  six 
weeks  before  performing  a  second  operation. 

4.  After  the  entrance  into  the  interior  of  the  eye  of  a 
foreign  body  consisting  of  iron,  if  it  is  found  impossible 
to  remove  it  with  a  small  magnet,  an  attempt  to  extract  it 
with  a  large  magnet  may  nevertheless  be  made  as  soon  as 
possible. 

Disinfection. 

Having  considered  the  various  precautionary  and  other 
preliminary  measures  with  which  the  eye  must  be  pro- 


DISINFECTION.    .  69 

tected  in  ophthalmic  operations  in  order  to  prevent  the 
entrance  into  the  wound  of  the  living  causes  of  inflamma- 
tion, which  are  ever  ready  to  invade  the  wound  and  may 
become  the  cause  of  serious  mischief,  it  will  now  be  in 
order  to  consider  what  is  the  best  thing  to  be  done  if,  in 
spite  of  every  care  and  precaution,  the  wound  never- 
theless becomes  infected.  At  the  same  time  we  shall 
learn  how  accidental  wounds  of  the  eye — that  is,  wounds 
due  to  injury,  which  have  become  infected — are  to  be 
treated. 

While  the  general  surgeon,  when  confronted  with  in- 
fected wounds,  as  a  rule  has  the  advantage  of  being  able 
to  adopt  fairly  vigorous  disinfecting  measures  in  the  tissues 
with  which  he  has  to  deal  (aside  from  the  intracranial 
space  and  a  few  other  localities),  the  delicate  structure  of 
the  tissues  of  the  eye — particularly  of  the  cornea,  where 
the  greatest  care  is  necessary  to  avoid  causing  an  opacity — 
will  not  permit  the  use  of  vigorous  measures  for  disinfec- 
tion. The  oculist,  in  a  sense,  has  his  hands  tied,  and  so 
far  as  the  sight  is  concerned,  at  least,  it  would  be  useless 
to  free  the  eye  from  infection  at  the  cost  of  the  trans- 
parency of  the  refracting  media — the  cornea,  lens,  and 
vitreous. 

When  the  anterior  chamber  has  become  the  seat  of  in- 
fection, vigorous  irrigation  with  disinfecting  solutions  is  a 
measure  that  naturally  suggests  itself.  Infection  of  the 
anterior  chamber  is  recognized  by  the  occurrence  of  iritis, 
either  of  a  purulent  character  or  merely  with  fibrinous 
exudate  or  deposits  on  Descemets  membrane.  As  early 
as  the  year  1878,  when  I  attempted  to  apply  Lister's 
system  to  the  eye,  I  convinced  myself  by  extensive  in- 
vestigations, chiefly  on  animals,  that  carbolic  acid  in  the 
strength  of  3  per  cent.,  which  is  the  minimum  of  efficiency, 
is  not  tolerated  by  the  anterior  chamber  and  particularly 
by  the  cornea.  The  cornea  becomes  opaque  as  the  result 
of  destruction  of  the  endothelium  of  Descemets  mem- 
brane by  the  disinfectant.  The  opacity  of  the  cornea  is 
most  intense  and  permanent  if  the  action  of  the  carbolic 


70  GENERAL   CONSIDERATIONS. 

acid  is  severe  enough  to  destroy  Descemets  membrane. 
This  fact  was  later  confirmed  as  regards  bichlorid  of  mer- 
cury by  unfortunate,  accidental  experiences  with  human 
subjects. 

Alfr.  Gräfe  found,  to  his  sorrow,  that  occasionally,  if  during  and 
after  an  operation  for  cataract  he  irrigated  the  operative  field  copiously 
with  a  slightly  warmed  2  per  cent,  solution  of  bichlorid  of  mercury, 
an  intense  and  persistent  opacity  of  the  cornea  developed  which  might 
require  weeks  to  clear  up  and  in  some  cases  never  disappeared.  Pre- 
liminary cocainization  of  the  eye  evidently  tends  to  reinforce  the  effect 
of  the  bichlorid.  The  effect  of  cocain  is,  on  the  one  hand,  to  increase 
the  absorbtive  power  of  the  cornea  and,  on  the  other  hand,  greatly  to 
facilitate  the  entrance  of  the  irrigating  fluid  into  the  anterior  chamber. 
For,  when  the  eye  has  been  thoroughly  cocainized  before  an  operation 
for  cataract,  the  intra-ocular  tension  is  greatly  reduced,  often  before  the 
delivery  of  the  lens,  but  particularly  after  the  lens  has  been  removed, 
and  especially  in  rigid,  senile  eyes.  Even  before  the  era  of  cocain  a 
marked  depression  of  the  cornea  with  or  without  the  entrance  of  air 
into  the  anterior  chamber  had  occasionally  been  observed  at  the  end  of 
operation  in  eyes  of  this  kind.  Cocain  analgesia  increases  this  condi- 
tion of  marked  diminution  of  intra-ocular  tension  by  rendering  the 
operation  painless,  and  therefore  preventing  the  contraction  of  the  ex- 
ternal eye  muscles  which  compress  the  globe.  Hence,  if  the  capsule  is 
rigid,  intra-ocular  tension  is  considerably  diminished,  and  not  only  air 
and  blood,  but  irrigating  fluid  also,  may  be  aspirated  into  the  anterior 
chamber.  If  a  large  quantity  of  the  latter  fluid  enters  the  anterior 
chamber,  the  endothelium  of  Descemet's  membrane  and  ultimately  the 
membrane  itself  may  be  injured.  Thus  Alfr.  Gräfe  saw  6  out  of  150 
cataract  patients  leave  his  clinic  with  a  corneal  opacity  so  that  they 
could  not  see  much  better  after  the  operation  than  before  (Bunge). 
Hence,  we  can  not  use  the  strong  fluid  disinfectants  to  cleanse  the 
anterior  chamber.  On  the  other  hand,  flushing  out  the  chamber 
merely  with  an  indifferent  fluid,  such,  for  example,  as  physiologic  salt 
solution,  is  in  most  cases  inadequate,  nor  is  mere  evacuation  of  the  con- 
tents of  the  anterior  chamber  through  a  corneal  puncture,  even  if  it  be 
repeated,  sufficient  to  prevent  infection. 

Having  introduced  iodoform  into  the  eye  in  about  50 
cases  I  may  say,  as  a  result  of  my  observations  in  these 
cases,  that  the  drug  is  probably  the  best  we  now  have  for 
intra-ocular  disinfection.  Although  it  is  undeniable  that 
in  many  cases  in  which  the  infection  is  very  virulent  or 
has  spread  extensively  in  the  interior  of  the  eye,  the 
remedy  fails,  it  is  nevertheless  true  that  in  many  cases  the 
results  obtained  are  good  or  at  least  fair.      Similar  ob- 


DISINFECTION.  71 

servations  have  been  made  in  other  clinics.  The  hope  I 
expressed  in  my  first  paper  on  iodoform  disinfection — 
that  it  might  protect  the  other  eye  against  sympathetic 
inflammation — has,  however,  unfortunately  not  been  real- 
ized. 

Iodoform  should  be  introduced  into  the  anterior  cham- 
ber or  into  the  vitreous  in  the  form  of  a  thick  pencil  from 
ö  to  7  mm.  in  length.  If  the  wound,  either  operative  or 
traumatic,  is  a  large  one,  small  discs  may  be  used,  the 
convex  side  of  which  may  be  applied  to  a  curved  incision 
without  introducing  any  air  into  the  wound,  as,  for  ex- 
ample, in  the  case  of  a  cataract  wound. 

The  pencils  and  discs  must  be  prepared  in  such  a  way  a<  to  pul- 
verize readily  when  they  come  in  contact  with  a  fluid,  the  iodoform 
being  thus  enabled  to  spread  out  over  a  considerable  area  in  the  an- 
terior chamber  or  in  the  vitreous.  In  this  way  its  disinfecting  power 
is  enhanced.  At  the  same  time  the  pencils,  especially  the  thinner 
ones,  must  be  hard  enough  to  be  readily  introduced  through  a  small 
wound.  The  desired  degree  of  hardness  may  be  obtained  by  adding  a 
small  quantity  of  sterilized-gelatin  solution  and  subjecting  the  mass  to 
a  great  pressure,  the  iodoform  gelatin  paste  being  pressed  through  the 
point  of  a  metal  syringe  provided  with  a  screw  piston  ;  the  caliber  of 
the  syringe  at  the  point  must  be  equal  to  1  mm.  The  thread  of  iodo- 
form is  received  on  a  sterilized  glass  plate  and  cut  up  into  pencil-  with 
oblique  ends,  to  facilitate  their  introduction  into  wounds. 

The  preparation  of  the  iodoform  pencils  and  discs  which  I  use  and 
recommend  has  been  accurately  described  by  I>r.  Sidler-Huguenin,  who 
has  so  far  exclusively  attended  to  their  preparation  ;  for  it  is  obvious 
that  every  precaution  must  be  observed  in  the  preparation  of  this 
material.  J.  Bernheim  demonstrated  by  certain  investigations  carried 
out  in  our  laboratory  that  iodoform  maybe  polluted  with  microbes,  and 
with  pathogenic  microbes  at  that.  Sidler-Huguenin,  who  has  fre- 
quently washed  iodoform  out  in  a  3  per  cent,  solution  of  carbolic  acid, 
often  found  unorganized  particles  of  matter,  splinters  of  wood  and  the 
like,  which  would  be  capable  of  causing  irritation  in  the  interior  of  the 
eye.  As  the  number  of  microbes  that  we  have  to  combat  is  always  an 
important  feature  in  disinfection,  their  number  must  not  be  still  more 
increased  by  the  introduction  of  the  iodoform  into  the  interior  of  the 
eye.  For  this  reason  the  iodoform  preparations  must  be  sterile  and 
must  be  kept  sterile.  In  removing  them  from  the  glass  tubes  in  which 
they  are  put  up  by  the  trade,1  a  sterilized  forceps  should  be  used,  which 
must  be  absolutely  dry,  else  the  pencils  will  break  up  as  soon  as  they 
are  within  the  grasp  of  the  forceps. 

1  This  is  done  by  the  Apotheke  zur  Post,  Kreuzplatz,  Zurich  V. 


72  GENERAL  CONSIDERATIONS. 

Plate  i. 

Introduction  of  a  pencil  of  iodoform  into  the  anterior  chamber 
case  of  infection  by  a  foreign  body. 


The  iodoform  pencils  may  be  introduced  either  through 
the  already  existing  wound  or  through  an  incision.  One 
pencil  is  usually  enough  for  the  anterior  chamber ;  but 
under  certain  circumstances  it  may  be  advisable  to  intro- 
duce two  or  three  into  the  vitreous,  depending  on  the 
extent  of  the  infectious  inflammation. 

The  method  of  introducing  the  pencil  into  the  anterior 
chamber  is  shown  in  Plate  1,  illustrating  a  case  in  which, 
after  the  removal  of  a  spicule  of  iron  with  the  aid  of  my 
large  magnet,  signs  of  infection  developed,  with  the  accu- 
mulation of  pus  in  the  anterior  chamber.  As  in  this  case 
the  wound  from  which  the  foreign  body  had  been  ex- 
tracted was  already  closed,  an  incision  was  made  into  the 
temporal  half  of  the  cornea  with  a  Gräfe  cataract-knife, 
and  the  pencil,  which  was  held  with  a  curved  iridectomy 
forceps  with  serrated  jaws,  rapidly  introduced  through 
this  incision.  Jt  is  important  to  see  that  no  aqueous 
humor  escapes  during  the  incision.  The  accident  can 
easily  be  avoided  if  the  eye  is  well  cocainized  and  the 
knife  is  sharp.  The  introduction  should  be  effected 
rapidly,  to  guard  against  premature  melting  of  the  iodo- 
form pencil.  Finally,  in  order  to  prevent  the  pencil  from 
slipping  out  of  the  anterior  chamber,  great  care  must  be 
taken  to  see  that  it  is  introduced  rapidly  and  that  all  of 
it  enters  the  chamber.  This  is  best  accomplished  by  first 
introducing  it  as  far  as  possible  with  the  forceps,  then 
releasing  it  for  a  moment  and  pushing  it  in  the  rest  of 
the  way  with  the  closed  forceps,  which  is  therefore  used 
like  a  delicate  probe.  In  this  way  the  freely  movable 
pencil  can  be  properly  placed  in  the  anterior  chamber. 
If  there  already  is  a  large  wound  in  the  cornea  or  in  the 
sclera,  the  jaws  of  the  introducing  forceps  should  not  be 
released  until  the  pencil  is  completely  within  the  anterior 
chamber  or  vitreous  body. 


V 


y%8ii       '  "^ 


DISINFECTION.  73 

The  incision  should  be  no  larger  than  absolutely  neces- 
sary, but  it  should  not  be  too  small — that  is  to  say,  for 
pencils  1  mm.  in  diameter  the  incision  should  be  made 
with  a  narrow  Gräfe  knife,  and  not  with  a  keratome,  be- 
cause with  the  former  instrument  the  internal  wound  (in 
Descemet's  membrane)  can  be  made  as  large  as  the  ex- 
ternal wound,  and  the  wound  canal  in  the  cornea  therefore 
does  not  become  narrow  as  it  approaches  the  anterior 
chamber.  Another  advantage  of  the  narrow  Gräfe  knife 
is  that  it  is  better  adapted  for  puncturing  and  cutting 
than  the  keratome.  The  same  considerations  obtain  for 
incision  of  the  sclera.  If  that  procedure  becomes  neces- 
sary, the  coat  must  first  be  properly  exposed  by  incising 
the  conjunctiva  and  Tenon's  capsule  so  that  the  subse- 
quent incision  of  the  membrane  may  remain  constantly 
exposed  to  view.  If  the  conjunctiva  and  sclera  are 
incised  at  the  same  time,  the  rapid  introduction  of  the 
pencil  may  be  impossible  because  the  sclera  wound  may  be 
missed. 

That  iodoform  is  well  borne  by  the  anterior  chamber  I  learned  from 
my  earliest  experiences  in  the  year  1892,  when  I  treated  tuberculosis 
of  the  iris  and  suspicious  cases  of  tuberculous  iritis  with  deposits  by 
the  introduction  of  iodoform  pencils.  From  that  it  was  a  natural  step 
to  employ  the  remedy  against  a  purulent  infection,  because  I  had 
always  considered  iodoform  a  useful  antiseptic  and  had  used  it  in  the 
treatment  of  the  wound  after  a  cataract  operation.  It  is,  however,  to 
be  observed  that  when  there  is  intense  infectious  inflammation  in  the 
anterior  chamber,  a  fairly  heavy  opacity  sometimes  develops  in  the 
cornea  at  the  point  where  the  iodoform  is  placed,  and  it  occasionally 
happens  that  the  corneal  opacity  does  not  disappear  altogether.  It  is 
therefore  advisable  not  to  place  the  iodoform  immediately  in  front  of 
the  pupil,  whenever  that  can  be  avoided.  It  appears  that  the  toxins 
generated  by  the  inflammatory  process,  acting  together  with  the  iodo- 
form, are  capable  of  injuring  the  endothelium  of  Descemet's  mem- 
brane. Nevertheless,  in  eyes  that  have  gradually  become  free  from 
inflammation,  remains  of  iodoform  may  be  seen  even  on  the  lens  with- 
out producing  any  opacity. 

The  iodoform  is  gradually  removed  from  the  anterior 
chamber  by  absorption,  and  I  have  often  seen  it  remain 
there  without  producing  any  irritation  after  the  inflamma- 


74  GENERAL   CONSIDERATIONS. 

tion  (for  the  removal  of  which  its  use  was  necessary)  had 
long  ago  disappeared. 

Iodoform  is  also  well  tolerated  by  the  vitreous  body, 
from  which  it  also  gradually  disappears.  Disinfection  of 
the  vitreous,  however,  may  obviously  be  a  most  difficult 
task,  as  the  germs  may  spread  over  such  a  large  area  that 
they  can  not  be  reached  and  controlled  with  iodoform.  In 
disinfecting  with  iodoform,  as  with  any  other  disinfectant, 
the  generally  familiar  observation  is  made  that  the  sooner 
disinfection  is  begun,  and  the  milder  the  infectious  process, 
the  more  probably  will  our  eiforts  at  disinfection  be 
crowned  with  success.  The  virulence  of  the  infectious 
process  depends  not  only  on  the  relation  between  the  ac- 
tivity of  the  microbes  on  the  one  hand,  and  that  of  the 
tissue  attacked  on  the  other,  but  also  on  the  kind  of  germs 
that  are  present.  It  appears  that  in  the  case  of  certain 
varieties  of  bacilli,  which  are  extremely  pathogenic  for 
the  eye,  and  which  most  frequently  effect  an  entrance 
along  with  splinters  from  a  hoe,  are  too  virulent  for  iodo- 
form disinfection,  and  in  these  cases  the  method  is  apt  to 
prove  futile.  I  named  these  organisms  panophthalmia 
bacilli  and  they  were  later  recognized  by  Silberschmidt 
and  Römer  as  belonging  to  the  group  of  hay  bacilli.  The 
method  may,  of  course,  prove  a  failure  with  other  mi- 
crobes, especially  if  the  drug  is  not  brought  into  suffi- 
ciently close  contact  with  the  germs,  or  the  latter  can  not 
for  some  reason  be  brought  sufficiently  within  its  influence. 
Thus,  even  Descemets  membrane  is  sufficient  to  prevent 
a  purulent  ulcer  of  the  cornea  from  being  adequately  in- 
fluenced by  iodoform  introduced  into  the  anterior  chamber, 
and  for  this  reason  the  treatment  of  ulcus  serpens  by  in- 
troducing iodoform  into  the  anterior  chamber  is  not  a 
suitable  one. 

Iodoform  acts  slowly  and,  therefore,  does  not  injure  the 
tissues  with  which  it  comes  in  contact,  and  if  it  can  be 
confined  within  a  narrow  space  along  with  the  pathogenic 
germs  that  have  entered  the  eye,  and  the  tissues  are  en- 
abled  to  develop  their  normal  power  of  resistance,  the 


DISINFECTION.  75 

attempt  to  render  the  microbes  innocuous  may  be  success- 
ful ;  for  it  is  not  necessary  to  kill  the  germs,  if  only  they 
are  prevented  from  multiplying. 

That  is  why  intra-ocular  disinfection  with  iodoform 
quite  often  yields  very  favorable  results  if  the  method  is 
adopted  early  and  carried  out  properly.  On  the  other 
hand,  it  is  practically  incapable  of  doing  any  harm,  so  far 
as  my  experience  has  gone. 

This  method  of  treating  the  interior  of  the  eye  with 
iodoform  is  specially  adapted  for  the  treatment  of  infected 
traumatic  or  operative  wounds  that  have  penetrated  deep 
into  the  eye,  as,  for  example,  wounds  due  to  the  entrance 
of  foreign  bodies  or  any  large  pointed  or  cutting  objects. 
It  can  also  be  used  to  advantage  after  cataract  operations 
that  do  not  heal  kindly,  especially  if  an  insidious  irido- 
cyclitis with  deposits  persists  for  some  time  and  keeps  the 
eye  from  quieting  down.  I  have  observed  very  favorable 
results  in  scars  that  have  suppurated  after  operation,  and 
which  have  become  very  angry. 

Superficial  wounds  that  showr  signs  of  infection  may  also 
be  disinfected  by  means  of  heat,  either  with  the  galvanic- 
electric  platinum  loop  or  Pacquelin's  benzin  cautery.  If 
the  effect  of  heat  is  desired  in  the  depth  of  the  wound,  the 
latter  method  alone  is  to  be  recommended,  because,  when 
the  galvanic-electric  loop  is  introduced  into  a  moist  tissue, 
the  current  is  short-circuited  by  the  moisture  of  the  tissues 
and  the  loop  at  once  begins  to  cool.  When  Pacquelin's 
cautery  is  used  for  the  eye,  it  should  be  fitted  with  a 
specially  fine  point.  Disinfection  by  cauterization  is  al- 
ways attended  by  the  disadvantage  that  the  dead  tissue 
may  become  the  seat  of  further  bacterial  growth.  There 
is  also  danger,  if  the  cauterization  in  the  deeper  portions 
of  the  eye  is  thorough,  that  the  destruction  may  be  so 
great  as  to  cause  marked  cicatricial  contraction  and  ret- 
inal detachment.  [The  editor  can  substantiate  the  author's 
statements  in  regard  to  iodoform  under  the  circumstances 
detailed.  Opening  of  the  wound  and  daily  drainage  of  the 
anterior  chamber  is,  according  to  Knapp,  the  most  efficient 


76  GENERAL   CONSIDERATIONS. 

method  of  combatting  infections  of  the  eye  after  cataract 
extraction.  For  certain  infections,  limited  to  the  anterior 
portion  of  the  eye,  and  nnassociated  with  the  formation 
of  ring  abscess  in  the  cornea,  but  with  fibrinous  exudate 
in  the  anterior  chamber,  dionin  in  5  per  cent,  solution 
has  an  excellent  effect ;  the  same  is  true  of  a  25  per  cent, 
solution  of  argyrol. — Ed.] 

Instruments. 

A  few  remarks  about  instruments  may  not  come  amiss. 
It  is  evident  that  operations  on  such  an  important  organ 
as  the  eye  call  for  instruments  which  must  be  of  the  very 
best  make  and  in  absolutely  perfect  condition.  The  success 
of  an  ophthalmic  operation  is  often  entirely  dependent  on 
the  excellence  and  proper  construction  of  the  instruments 
used.  Above  all,  the  cutting  and  puncturing  instruments 
with  which  the  capsule  of  the  bulb  is  opened — that 
is,  cataract  knives,  needles,  capsule  knives,  discission 
needles,  and  the  like,  must  be  as  perfect,  with  regard  to 
their  edges  and  points,  as  it  is  possible  to  make  them. 
For  this  reason  an  instrument  of  this  kind  can  not  be 
used  any  length  of  time,  no  matter  how  careful  the  opera- 
tor may  be,  without  being  reground. 

The  cornea  and  sclera  are  tough  and  hard  to  cut ;  hence, 
only  properly  constructed  and  properly  sharpened  instru- 
ments are  capable  of  making  a  smooth  incision.  The 
smoother  the  incision,  the  more  easily  and  the  more 
quickly  will  union  of  the  wound  and  healing  take  place. 
When  the  edges  of  the  wound  are  bruised  and  torn  they 
are  covered  with  partially  or  totally  contused  and  dead 
particles  of  tissue  which  must  first  be  cast  off  or  absorbed 
before  healing  can  take  place.  Such  tissue  elements, 
which  have  been  destroyed  by  the  incision,  are  also  quite 
capable  of  becoming  culture  media  for  pathogenic  micro- 
organisms. The  sooner  union  and  healing  take  place  in 
the  wound,  the  better  is  the  prospect  of  preventing  the 
growth  of  bacteria,  in  other  words,  secondary  wound  in- 


INSTRUMENTS.  77 

fection.  Secondary — i.  e.,  post-operative — infection  is  a 
special  danger  in  wounds  of  the  eye  because  the  operative 
field  can  not  be  rendered  or  maintained  absolutely  sterile. 
For  this  reason  a  smooth  incision,  made  with  a  sharp  in- 
strument, and  with  as  little  contusion  of  the  edges  of  the 
wound  as  possible,  is  a  strung  guarantee  of  a  smooth  re- 
covery. Properly  constructed  instruments  and  proper 
care  in  keeping  them  in  order  are,  therefore,  two  impor- 
tant factors  influencing  the  result  of  operations  on  the 
eye. 

A  good  polish  is  very  important  for  knives,  needles, 
and  scissors.  In  the  first  place  it  has  much  to  do  with 
the  smoothness  of  the  incision  and  the  absence  of  con- 
tusion of  the  wound  edges.  In  the  second  place,  an  in- 
strument that  is  perfectly  polished  is  less  apt  to  become 
soiled,  and  is  much  more  easily  cleansed ;  and  for  this 
reason  all  instruments,  whether  cutting  or  non-cutting 
(strabismus  hooks,  spatulas,  specula,  and  the  like),  should 
always  be  as  smooth  and  bright  as  possible.  Good  polish 
and  smooth  finish  are  strong  guarantees  of  asepsis.  It 
has  been  proved  that  a  well-polished  instrument  may  be 
rendered  germ  free  or  nearly  so  by  simple  mechanical 
rubbing.  If,  in  addition,  the  precaution  is  taken  to  see 
that  an  instrument  is  never  very  badly  soiled  by  allowing 
shreds  of  tissue  from  the  wound  to  adhere  to  the  blade, 
I  find  by  years  of  experience  that  knives,  keratomes,  dis- 
cission needles  and  the  like  can  be  disinfected  or  kept 
aseptic  with  the  least  degree  of  injury  to  the  cutting  edge 
by  placing  them  for  ten  minutes  in  a  3  per  cent,  solution 
of  carbolic  acid  and  rubbing  them  well  with  sterile  gauze 
or  cotton  while  in  the  solution.  In  the  twenty-five  years 
that  I  have  used  this  method  in  my  private  institu- 
tion I  have  never  had  a  single  case  of  primary  wound- 
infection  after  an  operation  for  cataract,  and  altogether 
only  1  case  of  suppuration,  which  began  on  the  fifth  day 
after  operation,  and  could,  therefore,  hardly  have  been 
caused  by  the  instrument. 

If  it  is  desired  to  boil  cutting  and  puncturing  instru- 


78  GENERAL   CONSIDERATIONS. 

ments,  great  care  must  be  taken  to  guard  both  edge  and 
polish  against  injury.  Boiling  for  ten  minutes  in  a  1  per 
cent,  solution  of  sodium  carbonate  renders  them  sterile,  at 
least  as  regards  the  ordinary  pathogenic  germs.  The 
coating  of  soda  which  adheres  to  the  instruments  after 
boiling  and  spoils  the  polish  must  be  removed  at  once,  and 
this  is  best  effected  by  transferring  the  instruments,  or 
the  vessel  containing  them,  from  the  boiling  water  into 
sterilized  water  or  sterilized  salt  solution.  Great  caution 
must  be  observed,  however,  to  see  that  the  sterilized  fluids 
really  are  sterile. 

Instruments  with  ivory  handles  may  also  be  boiled  ;  but  after  a  time 
the  ivory  deteriorates  and  becomes  rough,  so  that  perfectly  smooth 
handles  made  of  metal  and  well  nickel-plated  are  to  be  preferred.  The 
cross-pieces  with  which  some  instrument  makers  provide  the  metal 
handles  are  undesirable  and,  in  fact,  useless. 

In  a  large  clinic  service  there  is  no  doubt  that  the  most 
convenient  and  safest  method  of  sterilizing  that  has  yet 
been  devised  is  by  boiling  at  least  all  non-cutting  instru- 
ments ;  and  treating  cutting  and  puncturing  instruments 
with  the  previously  mentioned  precautions. 

Keeping  the  instruments  constantly  moist  during  the 
operation,  by  returning  them  to  a  sterilized  fluid  every 
time  they  are  used,  has  the  great  advantage  that  it  pre- 
vents pieces  of  tissue  adhering  and  renders  them  easier  to 
cleanse.  The  cleansing  should  be  done  soon  after  the 
operation,  because,  if  the  instruments  are  left  in  the  fluid 
any  length  of  time,  both  the  polish  and  the  edge  suffer. 
It  was  formerly  customary,  when  necessary  to  use  two 
instruments  in  rapid  succession,  as,  for  example,  the 
cystotome  and  a  curet,  to  attach  them  to  the  same  handle  ; 
and  this  is  still  sometimes  done  (Fig.  29).  But  it  is  not 
to  be  recommended,  nor  is  it  necessary,  since  we  know 
that  rapidity  during  the  operation  is  not  an  important 
factor.  The  danger  is  that  in  using  such  an  instrument 
the  end  which  is  turned  away  from  the  eye — for  example, 
the  curet-end — may  be  soiled  by  coming  in  contact  with 
some  other  object  while  the  cystotome  is  being  used,  for  it 


INSTRUMENTS.  79 

is  impossible  to  watch  both  ends  of*  an  instrument  and  at 
the  same  time  the  entire  operative  field. 

An  Instrumentarium  for  operations  on  the  eye  which 
shall  contain  the  most  necessary  instrument-  is  composed 
as  follows  : 

2  Desmarres'  eye  specula, 

1    Spring-  speculum  after  Bowman,  Snowden,  etc., 

1  Desmarres'  lid  clamp  or  entropion  forceps, 

2  Knapp  or  Snellen  lid  clamps, 
1   Jäger  horn  spatula, 

1  Cilia  forceps, 

1  Fixation  forceps,  with  catch, 

1  Fixation  forceps,  without  catch, 

1  Curved  fixation  forceps, 

1  Heavy  straight  fixation  forceps, 

1  Fine  straight  conjunctival  forceps, 

1  Curved  iris  forceps,  with  hooks, 

1  Curved  and  serated  iris  forceps, 

1  Heavy  curved  Cooper  scissors, 

1  Large  heavy  scissors, 

1  Small  straight  sharp-pointed  scissors, 

1  Curved  strabismus  scissors,  with  blunt  ends, 

1  Curved  sharp  iridectomy  scissors, 

1  Wecker's  scissors, 

5  Grate's  cataract-knives, 

5  Keratomes  of  various  widths, 

2  Bowman  discission  needles, 

2  Knapp's  capsule  knives, 

3  Large  and  small  scalpels, 

1  Weber's  knife  for  splitting  the  canaliculi,  straight, 

1  Weber's  knife  for  splitting  the  canaliculi,  curved, 

1  Gräfe's  cystotome, 

1  Schweigger's  cystotome, 

1  Daviel  lens-scoop, 

1  Hard-rubber  or  glass  scoop  for  delivering  the  cataract, 

1  Critchett's  scoop, 

1  Broad  wire  loop,  after  Weber, 

1  Xarrow  wire  loop,  after  Snellen, 


80  GENERAL  CONSIDERATIONS. 

1  German  silver  spatula  for  replacing  the  iris, 

2  Strabismus  hooks,  large  and  small, 

1  Double  Wecker  hook  or  Prince  forceps  (angular),  for 

muscle  advancement, 

2  Large  double  hooks, 
2  Small  double  hooks, 
1  Single  small  hook, 

1   Pointed  iris  hook, 
1  Blunt  iris  hook, 
6  Pean  or  Langenbeck  hemostats, 
12  Best  curved  needles,  large  and  small, 
1  Needle-holder, 
1  Myrtle-leaf  probe. 
4  Bowman's  lacrimal  probes, 

1  Conical  probe, 

2  Glass  syringes. 

The    possession    of   the  following  instruments  is  also 
desirable  : 

Desmarres'  capsule  forceps, 
1   Couching  needle, 
1  Beer  cataract-knife, 
1   Straight  cataract-knife  (Beer), 
1  Blunt  Desmarres'  knife, 

Knapp's  curved  knife-needles  (curet-hook), 

Lang's  knives  for  separating  anterior  synechia?, 

Pellier's  eye  speculum, 

Müller's  retractors  for  extirpating  the  lacrimal  sac. 

Instrumentarium  for  Krönlein's  operation  : 
Galvanocautery  and  large  moist  cell, 
Pacquelin's  thermocautery, 
Giant  magnet, 
Small  magnet, 

Illuminating  apparatus  for  the   removal  of  foreign 
bodies  from  the  cornea,  after  Sidler-Huguenin. 


OPERATION  FOR   CATARACT.  81 

OPERATIONS  ON  THE  EYE. 

(A)  OPERATIONS  ON  THE  GLOBE. 
1.  OPERATION    FOR  CATARACT. 

The  removal  of  an  opaque  lens  is  one  of  the  most 
important  and  most  difficult  tasks  that  falls  to  the  lot  of 
the  ophthalmic  surgeon  ;  for  in  this  operation,  more  than 
in  any  other,  the  eve  is  exposed  to  the  danger  of  infection 
and  therefore  to  rapid,  purulent  inflammation  or  slow  and 
insidious  cyclitis,  which  may  even  eventually  cause  blind- 
ness of  the  other  eye.  The  operation  for  cataract,  espe- 
cially for  senile  cataract,  therefore  furnishes  a  touchstone 
for  the  ophthalmic  surgeon's  efficiency,  both  as  to  his 
operative  technic  and  the  prevention  of  surgical  compli- 
cations. 

As  cataract  is  much  more  common  in  later  life  than  in 
youth,  so-called  senile  cataract  forms  the  largest  and  most 
important  group.  It  should  be  mentioned,  however,  that 
age  merely  constitutes  a  predisposing  factor  and  that  the 
true  cause  of  cataract,  so  far  as  it  is  known  at  all,  lies  in 
disease  and  weakness  of  the  entire  body,  or  of  important 
organs,  or  of  the  eye  itself. 

The  division  into  juvenile  and  senile  cataract  was  sug- 
gested by  operative  considerations.  Up  to  the  age  of 
thirty  the  lens  is  uniformly  soft ;  after  that  period,  how- 
ever, the  central  fibers  of  the  lens,  owing  to  the  physio- 
logic hardening  of  the  tissues,  contract,  and  a  hard 
nucleus  is  formed,  which  in  the  course  of  years  con- 
stantly increases  in  size  and  hardness.  As  this  nucleus 
grows,  the  soft  cortex  naturally  diminishes  more  and 
more,  and  by  the  sixtieth  year  of  life  the  sclerosis  has 
usually  spread  to  the  capsule  of  the  lens. 

Physiologic  sclerosis  (the  cause  of  diminution  of  the 
power  of  accommodation  and  presbyopia)  has  nothing 
directly  to  do  with  the  formation  of  cataract ;  but  it  is  an 


82  OPERATIONS  ON  THE  EYE. 

important  factor  in  the  cataractous  process  because  the 
hardened  nucleus  for  the  most  part  resists  the  degenera- 
tion which  involves  the  rest  of  the  cataract  and,  forming 
a  solid  body,  plays  an  important  part  at  the  operation. 
When,  on  the  other  hand,  as  is  the  case  in  the  juvenile 
eye,  no  nucleus  has  been  formed,  the  entire  lens,  as  it 
softens,  is  converted  into  a  semifluid  mass  which  does  not 
contain  a  hard  nucleus. 

Sometimes  clouding  of  the  nucleus  is  prevented  by  the 
same  process  of  sclerosis,  and  after  the  cataract  has 
matured  a  fairly  clear  nucleus,  which,  as  a  rule,  has  a  yel- 
lowish color,  is  found  surrounded  by  the  grayish,  abso- 
lutely opaque  and  glue-like  cortical  substance.  In  such  a 
case  we  have  to  deal  with  a  senile,  cortical  cataract.  The 
development  of  cortical  cataract  begins  with  the  appear- 
ance in  the  cortex  of  striae  and  rows  of  punctate  opaci- 
ties, which  gradually  increase  in  number  and  radiate 
toward  the  center,  followed  by  the  appearance  of  gray 
wedges,  while  the  nucleus  retains  its  transparency  for 
some  time.  As  the  process  goes  on,  the  nucleus  may 
also  lose  some  of  its  transparency,  but  the  haziness  chiefly 
affects  the  cortex. 

Sometimes,  but  on  the  whole  less  frequently,  the  cata- 
ract begins  in  the  nucleus  and  immediately  contiguous 
surrounding  zone  of  cortex.  In  such  a  case  we  speak  of 
nuclear  cataract.  The  haziness  of  the  cortex  in  these 
cases  varies  both  as  regards  intensity  and  rapidity  of 
development.  It  sometimes  happens  that  complete 
opacity  does  not  develop  until  the  individual  has  reached 
an  advanced  age,  although  the  sclerosis  gradually  becomes 
more  firm. 

In  nuclear  cataract  the  visual  disturbance  appears  ear- 
lier and  is  more  intense  than  is  the  case  in  cortical  cata- 
ract ;  unless  the  latter  begins  with  an  anterior  or  poste- 
rior polar  opacity,  and  not,  as  is  usually  the  case,  at  the 
equator  of  the  lens. 

The  term  capsular  cataract,  finally,  is  applied  to  opaci- 
ties formed  by  proliferation  of  the  epithelial  cells  in  the 


OPERATION  FOR   CATARACT.  83 

capsule  of  the  lens.  The  entire  posterior  aspect  of  the 
anterior  lens  capsule  is  covered  by  a  single  layer  of  cap- 
sular epithelium.  In  cataract  formation  this  epithelium, 
as  a  rule,  begins  to  proliferate  at  the  center,  opposite  the 
anterior  pole ;  but  not  until  the  cataract  has  existed  for 
some  time  and  has  become  over-ripe  ;  so  that  anterior 
capsular  cataract  is  an  important  sign  of  "  over-ripeness  " 
of  the  cataract.  These  proliferations  of  capsular  epithe- 
lium are  recognized  by  the  white  color  in  contrast  to  the 
opaque  cortex,  which  is  more  gray  or  grayish  white,  and 
by  the  fact  that  they  form  at  the  anterior  pole  a  circular 
or  irregular  patch  which  gradually  increases  in  size  and 
often  appears  as  a  distinct  thickening  on  the  cortical 
opacity. 

In  those  cases  in  which  cataract  is  produced  by  some 
grave  disease  of  the  eye — complicated  cataract — anterior 
capsular  cataract  is  sometimes  found,  as,  for  example, 
when  cyclitis  or  retinal  detachment  has  been  followed  by 
profound  disorganization  of  the  eye,  with  cataract.  Ante- 
rior polar  or  pyramidal  cataract,  which  occurs  in  earlier 
life  as  a  result  of  ulcerative  perforation  of  the  cornea,  is 
another  form  of  capsular  cataract. 

It  follows  from  what  has  been  said  that  the  lens 
varies  in  accordance  with  age,  and  that  the  structure  of 
the  cataract  and  its  condition  greatly  influences  the  sur- 
geon in  his  choice  of  operative  procedures  for  its  re- 
moval. There  are  various  methods  of  removing  the  lens 
from  the  eye. 

1.  We  require  with  lenses,  which  as  yet  have  no  firm 
nucleus,  simply  to  open  the  anterior  capsule,  and  then 
to  leave  the  absorption  of  their  entire  contents  to  the 
eye  alone.  During  this  process  the  lenticular  masses, 
which  may  be  perfectly  clear  or  more  or  less  completely 
opaque,  gradually  enter  the  anterior  chamber  and  are 
there  absorbed.  The  process  of  absorption  may,  if  neces- 
sary, be  shortened  by  puncturing  the  anterior  chamber 
and  thus  evacuating  the  semifluid  lenticular  masses.  If 
the  lens  is  completely  opaque  at  the  time  the  capsule  is 


84  OPERATIONS  ON  THE  EYE. 

opened — as,  for  example,  as  the  result  of  total  congenital 
cataract  or  cataract  developing  early  in  life — absorption 
may  take  place  without  anything  further.  If,  on  the 
other  hand,  the  lens  is  only  partially  opaque  when  the 
capsule  is  opened,  as,  for  example,  in  lamellar  or  zonular 
cataract,  the  non-opaque  cortical  and  nuclear  masses 
must  first  become  cataractous  by  imbibition  of  aqueous 
humor,  which  causes  them  to  swell  and  protrude  into  the 
anterior  chamber,  where  they  then  undergo  absorption. 
If  the  lens  shows  no  haziness  whatever  when  the  capsule 
is  opened,  as,  for  example,  in  stab-wounds  or  in  the 
operation  for  myopia,  the  entire  lenticular  mass,  before  it 
can  be  absorbed  or  evacuated  by  puncture,  must  be  gradu- 
ally saturated  and  distended  with  aqueous  humor,  so  as 
to  become  cataractous  and  disintegrate. 

The  above-described  method  of  removing  the  lens 
therefore  implies  the  following  requisites: 

(«)  Good  absorbing  power  in  the  eye,  which  is  great- 
est in  youth  and  diminishes  with  advancing  age. 

(6)  Little  tendency  to  increased  tension  (glaucoma), 
which,  as  we  know,  is  an  almost  certain  result  of  trau- 
matic cataract.  The  tendency  to  glaucoma  is  less  in 
youth  than  in  old  age. 

(c)  The  lens  must  be  one  that  does  not  contain  a  hard 
nucleus,  because  the  latter  could  not  readily  be  absorbed 
in  the  anterior  chamber,  but  would  cause  irritation  and 
under  the  most  favorable  circumstances  would  require  a 
long  time  to  undergo  absorption. 

Simple  laceration  or  discission  of  the  anterior  capsule, 
with  or  without  subsequent  puncture  of  the  anterior 
chamber,  is  therefore  applicable  only  to  young  eyes  up  to 
the  age  of  thirty  to  thirty-five — L  e.,  before  any  marked 
nucleus  formation  lias  taken  place,  and  it  makes  no  dif- 
ference how  great  the  haziness  of  the  lens  at  the  time  of 
operation  ;  for  the  hazier,  the  more  readily  it  will  be 
removed  from  the  eye,  either  by  simple  absorption  or  with 
the  aid  of  puncture  of  the  anterior  chamber,  as  the  evacu- 
ation brought  about  by  that  procedure  is  the  more  com- 


OPERATION  FOR  CATARACT.  85 

plete,  the  greater  the  capacity  and  consequently  the  dis- 
integration of  the  lens. 

2.  It  is  obvious  from  the  foregoing  that  when  there  is 
marked  nucleus  formation — that  is,  after  the  thirtieth  to 
the  thirty-fifth  year  of  life — a  different  method  must  be 
adopted  for  the  removal  of  the  cataract.  Assuming  that 
the  conditions  for  cataract  operation  are  present,  we  must 
turn  our  thoughts  as  much  as  possible  to  the  nucleus; 
and  we  will  not  succeed  any  longer,  after  the  capsule  has 
been  opened,  with  mere  puncture  of  the  anterior  cham- 
ber— that  is,  with  an  incision  from  3  to  5  mm.  in  length — 
but  need  a  cataract  incision  so  large  that  this  nucleus  can 
readily  escape.  This  incision  need  not  be  so  large  in 
patients  of  thirty-five  to  forty-five  years  as  at  a  later 
period  of  life. 

Indications. — As  with  advancing  years  the  absorp- 
tive power  of  the  eye  diminishes  and  the  tendency  to 
glaucoma  increases,  the  indications  for  operation  are  also 
subject  to  variation.  It  is  important  to  reduce  to  a 
minimum  the  cataractous  masses  to  be  absorbed  after  a 
cataract  operation,  if  rapid  recovery  is  desired.  When- 
ever it  is  possible,  the  entire  contents  öf  the  capsule  must 
be  removed  at  the  operation.  If  we  proceed  properly  the 
nucleus  is  readily  expelled  ;  but  the  same  can  not  be  said 
of  the  cortex,  parts  of  which  often  adhere  to  the  capsule, 
especially  when  it  is  not  opaque.  In  such  a  case  the  cor- 
tical substance  becomes  hazy  after  the  operation,  through 
the  entrance  into  it  of  aqueous  humor,  and  has  to  be  ab- 
sorbed by  the  eye.  These  cortical  remains  often  interfere 
for  a  long  time  with  vision.  They  sometimes  encroach 
upon  and  irritate  the  iris,  and — most  important  of  all — 
conjure  up  the  danger  of  glaucoma. 

1.  For  this  reason  it  is  always  best  in  cases  of  cataract 
during  the  later  decades  of  life  to  wait  for  complete 
opacity  of  the  cortex — maturity  of  the  cataract — before 
operating ;  in  other  words,  until  the  conditions  are  such 
that  the  cortical  substance,  having  undergone  total  cata- 
ractous disintegration,  separates  completely  from  the  cap- 


86  OPERATIONS  ON  THE  EYE. 

sule  after  the  anterior  capsule  is  opened  and  slips  out  of 
the  wound,  either  bringing  the  nucleus  with  it  or  following 
immediately  after  the  nucleus  which  slips  out  ahead. 

It  is  not  always  altogether  easy  to  determine  whether  a 
cataract  is  ripe  in  this  sense.  In  the  great  majority  of 
senile  cataracts  conditions  are  such  that,  as  soon  as  the 
third  stage  has  been  reached,  operation  gives  the  best 
prospect  of  speedy  success. 

By  the  first  stage  is  meant  the  beginning  of  cataract,  Cataracta  in- 
cipiens ;  the  second  stage  is  that  of  swelling,  because  as  the  cloudiness 
increases  the  lens  begins  to  swell,  as  may  be  determined  by  noting  the 
diminution  in  the  depth  of  the  anterior  chamber.  During  the  second 
stage  the  cloudiness  of  the  cortical  substance  is  still  incomplete,  and  on 
examination  with  lateral  illumination  an  interval  can  be  made  out  be- 
tween the  lenticular  cloudiness  and  the  edge  of  the  pupil,  the  latter 
throwing  a  faint  shadow  on  the  cloudy  lens,  which  is  situated  some 
little  distance  behind  it. 

During  the  third  stage,  that  of  operative  maturity,  the  cloudiness 
of  the  lens  has  extended  to  the  capsule  and  therefore  as  far  as  the 
pupillary  margin,  so  that  the  shadow  of  the  latter  is  no  longer  seen. 
At  the  same  time  the  swelling  of  the  cloudy  lens  diminishes  during 
this  stage  and  the  original  depth  of  the  anterior  chamber  is  restored.  • 

During  the  fourth  stage,  that  of  over-ripeness,  the  cataract  is  seen 
gradually  to  contract ;  the  depth  of  the  anterior  chamber  is  therefore 
still  further  increased,  the  radiating  striatum  disappears  on  account  of 
the  continued  disintegration  of  the  cortex  and  is  replaced  by  the  pale, 
dotted  appearance  of  capsulary  cataract  which  begins  in  the  middle,  at 
the  anterior  pole.  Eventually  the  cortex  may  liquefy  and  allow  the 
nucleus  to  sink  to  the  bottom  of  the  resulting  fluid.  This  is  known  as 
a  Morgagnian  cataract  and  is  not  a  very  common  occurrence.  In  most 
cases  the  cataract  contracts  to  form  a  flat  tenacious  disc,  which  does 
not  separate  so  readily  from  the  capsule  as  is  the  case  during  the  third 
stage.  During  the  stage  of  over-ripeness  a  process  begins  which  is  of 
grave  import  from  the  operative  standpoint ;  the  suspensory  ligament 
of  the  lens,  zonule  of  Zinn,  atrophies,  and  tremulousness  of  the  over- 
ripe cataract  results — that  is,  the  cataract  trembles  with  every  move- 
ment of  the  eye.  Or  the  friable  character  of  the  zonule  in  an  over- 
ripe cataract  of  this  kind  may  not  be  recognized  until  it  tears  during 
the  operation  and  allows  the  vitreous  to  enter  the  wound. 

It  follows,  therefore,  that  over-ripeness  of  the  cataract  diminishes 
the  favorable  conditions  for  a  formal  operation  for  cataract  and  a 
smooth  recovery. 

Although  the  stage  of  maturity  is  the  best  for  opera- 
tion, the  surgeon  is  often  compelled  to  operate  before  this 
desirable  condition  is  present  because  the  patient  wishes 


OPERATION  FOP,   CATARACT.  8? 

to  recover  his  sight  as  soon  as  possible  in  order  to  guard 
against  any  accident  that  might  arise  on  account  of  his 
defective  vision.  It  is  especially  when  cataract  develops 
in  the  remaining  useful  eye  that  an  early  operation 
of  this  kind  may  be  absolutely  demanded.  Premature 
operation  may  also  become  necessary  when  both  cataracts 
develop  at  the  same  time  and  with  equal  intensity,  although 
in  most  cases  of  double  cataract  the  development  is  un- 
equal and  the  process  progresses  more  rapidly  in  one  eye 
than  in  the  other.  Fortunately,  in  some  eases  the  im- 
maturity, which  at  first  arouses  serious  anxiety  in  the 
surgeon,  is  only  apparent — that  is  to  say,  although  some 
portions  of  the  cortex  have  not  become  hazy,  the  result 
of  the  cataract  operation  is  nevertheless  a  favorable  one. 

(a)  It  occasionally  happens,  mostly  in  the  ease  of  old 
persons,  that  the  haziness  of  the  cortex  is  very  slightly  or 
not  at  all  pronounced.  The  cataract  is  a  dull-yellow 
or  brownish  color,  or  the  pupillary  region  may  appear 
perfectly  black — black  cataract  (Cataracta  nigra).  When 
the  eyes  are  examined  with  the  ophthalmoscope,  however, 
it  is  found  that  the  transparency  of  the  lens  is  greatly 
impaired  and  the  eyeground  can  only  be  seen  very  indis- 
tinctly. The  darker  the  pupil  appears  with  lateral  illumi- 
nation, the  darker  and  more  blurred  will  be  the  veiled 
background  of  the  eye.  As  a  rule,  eyes  of  this  kind 
possess  better  vision  than  those  with  the  ordinary  gray 
cataract.  A  lens  with  the  latter  variety  of  cataract  trans- 
mits the  rays  of  light  better  in  both  directions  than  is  the 
case  in  the  former  variety  of  cataract,  so  that,  on  the  one 
hand,  the  examiner  is  able  to  see  the  eyeground  with  some 
degree  of  accuracy,  and  the  patient,  on  the  other  hand, 
retains  the  power  of  recognizing  larger  objects.  Never- 
theless, the  impairment  of  vision  is  usually  sufficient  to 
cause  a  serious  disability  and  menace  to  the  patient. 

It  would  be  very  bad  practice  to  wait  for  the  develop- 
ment of  gray  discoloration  of  the  anterior  cortex  and 
blindness  before  operating  on  cataracts  of  this  kind. 
These  lenses  never  become  gray  or  entirely  opaque  like 


88  OPERATIONS  ON  THE  EYE. 

other  lenses,  because  they  have  no  cortex  to  become  gray. 
The  lenticular  sclerosis  in  these  cases  extends  as  far  as  the 
capsule,  either  prematurely  or  at  the  normal  time — that  is, 
after  the  sixtieth  year — and  this  hardening  change  protects 
the  lenticular  mass  from  disintegrating  into  a  gray,  semi- 
fluid material,  just  as  in  the  case  of  the  physiologic  hard- 
ening process  of  senility  which  prevents  disintegration,  so 
that  the  cataractous  lens  always  contains  a  nucleus  which 
may  vary  in  size.  The  size  of  the  nucleus  must  deter- 
mine the  size  of  the  incision  necessary  for  its  escape  at 
the  operation.  To  be  exact,  the  condition  in  these  cases 
is  not  a  cataract  formation,  but  merely  a  hardening. 
When  an  eye  of  this  kind  is  operated  upon,  the  opening 
of  the  capsule  is  immediately  followed  by  the  escape  of 
the  entire  contents  in  toto  in  the  form  of  a  large,  hard, 
amber  colored  or  brown  cataract ;  and  if  the  wound  has 
not  been  made  large  enough  the  delivery  of  the  cataract 
may  cause  great  difficulties.  After  the  escape  of  the 
cataract  the  pupillary  region  may  be  perfectly  clean  and 
without  a  trace  of  opacity.  A  cataract  of  this  kind  is, 
therefore,  mature  or  operable  even  before  it  has  become 
entirely  opaque  and  gray. 

(b)  Occasionaly  in  individuals  who  are  not  very  old  and 
in  cases  of  myopia  there  may  be  an  incomplete  haziness  of 
the  lens,  made  up  of  a  number  of  striae,  usually  radiating 
toward  the  center,  and  narrow  wedges  interspersed  with 
dots  and  small  patches,  chiefly  affecting  the  cortical  portion. 
But  the  nucleus  also  frequently  presents  delicate  punctate 
and  striate  opacities.  The  patients  see  as  through  a  screen 
and  vision  is  usually  imperfect,  and  although  they  are  still 
able  to  find  their  way,  they  are  in  danger  of  occasionally 
breaking  a  limb.  Sometimes  they  are  still  able  to  read 
coarse  print,  and  on  examination  with  the  ophthalmoscope 
the  eyeground  can  still  be  seen  indistinctly. 

This  variety  of  cataract  is  also  operable  if  the  opaque 
striae,  dots,  and  patches  extend  all  the  way  to  the  capsule 
of  the  lens ;  for  in  that  case  the  cortex  comes  away  al- 
most completely  from  the  capsule  at  the  operation.     It  is 


OPERATION  FOR  CATARACT.  89 

possible  for  some  of  the  cortex  to  remain  behind ;  but,  as 
a  rule,  it  would  be  useless  in  these  cases  to  wait  for  com- 
plete haziness  of  the  lens  to  develop. 

(c)  There  is  another  group  of  cataracts  susceptible  of 
operation,  although  the  cortex  is  only  partially  and  insuf- 
ficiently cloudy.  They  are  the  cases  of  cataract  in  which 
the  hardening  process  of  age  comes  to  our  aid,  that  is, 
cataracts  occurring  after  the  sixtieth  year,  in  which  the 
cortex  also  is  involved  in  the  sclerosis  and  has,  therefore, 
attained  a  consistency  which  enables  it  to  escape  from  the 
capsules  without  adhering  to  it.  As  a  matter  of  fact, 
most  lenses  might  be  extracted  without  any  more  ado 
after  the  sixtieth  year,  depending  only  on  the  degree  of 
hardening.  It  has  been  found,  however,  that  the  cata- 
ractous  process  often  spoils  our  calculations  by  interfering 
with  the  normal  hardening  of  the  cortex  and,  therefore, 
with  its  separation  from  the  capsule.  The  cortex  re- 
mains semitransparent  and  does  not  undergo  cataractous 
degeneration  ;  nor  does  it  harden  properly,  or  at  least  the 
hardening  is  only  partial,  and  when  cataracts  of  this  kind 
are  extracted,  a  considerable  portion  of  the  cortex  often 
remains  behind.  In  spite  of  this  fact,  however,  the 
period  of  disability  is  less  than  it  would  be  if  operation 
were  deferred  until  perfect  maturity,  which  in  these  cases 
often  occurs  very  late,  even  though  it  may  take  weeks  or 
even  months  before  the  patient  regains  his  eyesight. 

Although  it  is  always  a  serious  matter  to  leave  remains 
of  the  cortex  behind  when  operating  on  cataract  in  old 
persons,  the  danger  in  this  respect  has  nevertheless  been 
diminished  by  the  adoption  of  antiseptic  and  aseptic 
methods.  For  my  part  I  am  convinced  that  if  we  can 
succeed  in  protecting  the  wound  from  inflammation,  in 
other  words,  keep  it  aseptic,  the  eye  will  tolerate  a  con- 
siderable quantity  of  cataractous  material  that  has  been 
left  behind,  and  the  latter  will  eventually  be  absorbed,  pro- 
viding the  eye  is  kept  under  careful  supervision  and  the 
pupillary  action,  as  well  as  any  changes  in  pressure,  can 
be  controlled  with  suitable  drugs.     On  the  other  hand,  if 


90  OPERATIONS  ON  THE  EYE. 

the  anterior  chamber  has  become  infected  in  the  operation, 
even  if  the  infection  is  not  a  very  virulent  one,  the  situa- 
tion at  once  becomes  much  more  dangerons  in  the  pres- 
ence of  any  cataractous  remains,  because  the  latter  afford 
a  good  culture  medium  for  the  infectious  germs. 

The  modern  treatment  of  wounds  has  rendered  the 
outlook  in  operations  on  unripe  cataracts  much  more 
favorable. 

Attempts  to  render  unripe  cataracts  operable  by  arti- 
ficial maturation  have  been  in  vogue  for  some  time.  At 
one  time  this  was  done  by  making  one  or  several  small, 
preparatory  discissions  or  punctures  in  the  anterior  cap- 
sule, because  it  is  a  matter  of  common  observation  that 
slight  injuries  of  the  lens,  as,  for  example,  by  a  foreign 
body,  may  gradually  produce  complete  traumatic  cataract. 

The  procedure,  however,  fell  into  disrepute,  and  there  is 
no  doubt  that  it  was  formerly  a  dangerous  one,  and  often 
followed  by  an  undesirable  degree  of  irritation,  glaucoma, 
or  even  grave  inflammation.  It  has  been  again  recom- 
mended in  more  recent  times,  and  perhaps  this  is  another 
illustration  of  asepsis  rendering  possible  a  procedure 
which  before  its  advent  was  proscribed ;  but  so  far  I  have 
had  no  personal  experience  in  this  matter. 

A  much  more  harmless  method  of  inducing  maturity 
artificially  is  that  suggested  by  Foerster.  He  advises 
massage  of  the  cataract,  after  a  preliminary  iridectomy, 
using  a  suitable  blunt  instrument,  such  as  a  strabismus 
hook  or  curet,  with  which  the  center  of  the  cornea  is  to 
be  rubbed,  and  asserts  that  the  procedure  is  followed  in  a 
few  days  by  the  development  of  complete  opacity.  The 
method  is  suitable  in  many  cases  and  quite  worthy  of 
commendation,  but  I  have  often  found  that  in  slowly 
maturing  cataracts  this  massage  of  the  lens  fails  to  hasten 
the  development  of  opacity  sufficiently.  [More  effectual 
than  Foerster's  method  of  artificially  ripening  cataract  is 
paracentesis  of  the  cornea  and  internal  massage  directly 
on  the  anterior  capsule  of  the  lens  with  a  small  spatula,  a 
method  which  Knapp,  following  the  recommendations  of 


OPERATION  FOR  CATARACT.  91 

Ricaldi  and  Bettmann,  has  recently  advocated.  Simple 
paracentesis  of  the  cornea  with  external  massage,  as  recom- 
mended by  T.  R.  Pooley  and  J.  R.  White,  is  said  to  be 
effectual.  Should  cortical  remnants  be  found  after  the 
extraction  of  unripe  cataract,  they  may  be  removed  with 
the  help  of  a  syringe,  as  has  been  specially  recommended 
by  McKeown,  Lippincott,  and  others.  The  editor  has  not, 
however,  been  pleased  with  this  form  of  irrigation,  al- 
though in  the  hands  of  experienced  colleagues  it  finds 
much  favor.  He  believes  that  the  lens  may  be  safely 
extracted  even  if  it  is  in  part  unclouded,  certainly  after 
the  sixtieth  year,  and  prefers  extracting  an  unripe  cata- 
ract to  performing  a  ripening  operation. — Ed.]  Snellen, 
Horner,  and  others  long  ago  emphasized  the  fact  that  an 
iridectomy  usually  hastens  the  ripening  of  a  cataract  and 
that  this  is,  therefore,  one  of  the  most  important  reasons  for 
resorting  to  prdiminwy  iridectomy — that  is,  an  iridectomy 
performed  a  few  weeks  before  extraction  of  the  cataract. 
It  also  increases  the  chances  of  success  by  the  fact  that  a 
major  operation  is  divided  into  two  minor  operations,  each 
of  which  is  less  dangerous  by  itself.  Another  considera- 
tion is  that  the  preliminary  operation  has  a  desirable  edu- 
cational effect  on  the  patient  and  enables  the  operator  to 
determine  how  he  acts  under  the  knife,  information  which 
he  will  find  useful  to  guide  him  at  the  subsequent  extrac- 
tion. The  preliminary  operation  is  also  the  best  one  to 
combat  any  disposition  there  may  be  to  glaucoma,  which 
sometimes  develops  in  a  most  unpleasant  way  after  a 
cataract  extraction,  even  when  no  part  of  the  cataract  has 
been  left  behind. 

Preliminary  iridectomy  is  unquestionably  most  desir- 
able in  many  cases  and  is  especially  indicated  when  com- 
plications threaten,  either  during  or  after  the  operation, 
aside  from  insufficient  ripeness — be  it  that  the  eye  is  not 
entirely  normal,  as,  for  example^  in  high  myopia,  or  the 
patient's  strength  and  general  condition  necessitate  the 
greatest  caution.  A  preliminary  iridectomy  is  also,  as  a 
rule,  necessary  in  cases  of  true  complicated  cataract — 


92  OPERATIONS  ON  THE  EYE. 

that  is,  cases  in  which  there  has  been  iritis,  choroiditis, 
and  disease  of  the  vitreous. 

As  in  all  these  cases  a  secondary  operation  for  cataract 
is  usually  necessary,  it  is  true  that  three  operations  in  all 
have  to  be  performed.  But  why,  when  so  much  is  at 
stake,  should  not  this  course  be  pursued,  even  if  it  be 
somewhat  slower,  since  it  offers  greater  security  and  free- 
dom from  risk,  particularly  as  each  of  the  three  operations 
necessitates  only  a  short  period  in  bed  and  is  practically 
painless. 

The  diagnosis  of  maturity — that  is,  the  condition  in 
wThich  the  lens  is  suitable  for  operation — is  evidently  not 
a  simple  matter  and,  as  we  have  seen,  depends  on  other 
factors  besides  clouding  of  the  anterior  cortex.  Complete 
opacity  of  the  lens  is  also  more  difficult  to  recognize  posi- 
tively because  it  is  impossible  to  make  sure  that  the  pos- 
terior cortex  has  undergone  cataractous  disintegration  and 
will  separate  readily  from  the  capsule.  It  is  true  that  in 
most  cases  the  condition  of  the  posterior  cortex,  as  regards 
the  degree  of  opacity,  is  the  same  as  that  of  the  anterior 
cortex,  but  there  are  exceptions.  Thus,  it  may  happen 
that  after  the  extraction  of  a  cataract  which  seems  to  be 
entirely  opaque,  the  operator  is  surprised  to  find  that  a 
good  deal  of  the  cataractous  material  has  remained  behind. 
It  has  also  happened  when  the  anterior  cortex  presented 
Foerster's  maturity  that  the  posterior  was  not  in  the  same 
condition. 

In  addition  to  careful  inspection  of  the  lens  with  the 
aid  of  a  magnifying  glass  after  dilatation  of  the  pnpil,1 
and  the  other  factors  already  mentioned,  such  as  the 
depth  of  the  anterior  chamber,  the  change  in  the  shadow 
of  the  iris,  etc.,  the  functional  state  of  the  eye  affords 
some  information  as  to  the  degree  of  ripeness.     But  from 

1 1  wish  to  emphasize  particularly  a  caution  which  ought  not  need  to 
be  mentioned.  It  is  that  atropin  must  never  be  used  under  these  cir- 
cumstances to  dilate  the  pupil,  because  cataractous  eyes,  aside  from 
their  age,  are  naturally  prone  to  develop  glaucoma,  especially  while 
the  cataract  is  swelling;  for  this  reason  homatropin  [or  euphthalmin — 
Ed.]  should  always  be  preferred. 


OPERATION  FOR   CATARACT.  93 

what  has  already  been  said  it  would  evidently  be  wrong 
to  judge  of  the  operability  of  a  cataract  solely  by  the  con- 
dition of  the  eyesight  and  to  wait  until  the  affected  eye 
becomes  totally  blind. 

2.  Function. — Among  the  conditions  affecting  the  suc- 
cess of  the  operation  must  be  mentioned,  in  addition  to 
ripeness  of  the  cataract,  the  functional  condition  of  the 
affected  eye— that  is  to  say,  the  health  of  the  eye— espe- 
cially as  regards  the  deeper  portions  which  escape  inspec- 
tion in  advanced  stages  of  cataract,  and  are,  therefore, 
judged  only  by  investigating  the  function.  A  case  of 
cataract  can  not  be  regarded  as  operable  unless  the  eye  still 
possesses  a  certain  degree  of  vision,  at  least  for  move- 
ments of  the  hands  at  0.25  to  0.05  m. ;  it  is  impossible  to 
give  accurate  numbers. 

Whether  the  retina  still  retains  some  central  vision  may 
be  roughly  determined  by  noting  whether  the  patient  is 
still  able  to  perceive  movements  of  the  hands  or  the  flame 
of  a  candle  in  the  dark  at  a  distance  of  6  m.  The  latter 
test,  however,  in  the  case  of  cataract  includes  much  more 
than  the  center  of  the  retina,  because  an  opaque  lens  acts 
much  like  a  piece  of  ground  glass  held  before  the  eye, 
which  diffuses  the  light  from  the  candle  over  the  entire 
retina,  so  that  the  flame  can  be  perceived  even  when  a 
central  scotoma  is  present.  [The  function  of  the  center 
of  the  retina  should  be  tested  by  means  of  two  small 
flames,  which  under  normal  conditions  should  be  readily 
recognized  as  such  by  the  patient. — Ed.]  However,  the 
candle-test  also  reveals  the  light  sense  of  the  retina  and 
is  useful  on  that  account. 

The  degree  of  peripheral  vision  is  determined  by  means 
of  the  so-called  projection-test,  a  kind  of  measuring  of  the 
visual  field  by  means  of  a  coarse  stimulus  capable  of 
affecting  the  cornea  through  the  cataract.  The  patient  is 
taken  into  a  dark  room,  the  other  eye  is  bandaged,  and 
his  ability  to  localize  with  the  cataractous  eye  a  candle 
flame  in  various  portions  of  the  visual  field  is  tested,  the 
examiner  covering  the  patient's  eye  with  his  hand  while 


94  OPERATIONS  ON  THE  EYE. 

the  light  is  being  placed  at  the  desired  spot — above,  below, 
to  the  right,  to  the  left,  etc.  As  soon  as  the  eye  is  uncov- 
ered the  patient  should  be  able  to  point  to  the  light  with 
his  finger  at  once  and  unerringly.  With  unintelligent 
patients  this  test  must  be  repeated,  if  it  is  unsatisfactory 
the  first  time,  until  the  patient  learns  what  is  expected  of 
him.  Many  patients  also  believe  that  they  will  not  be 
operated  upon  unless  they  have  lost  their  vision  com- 
pletely and  therefore  give  incorrect  answers  in  order  to  be 
sent  home  without  operation.  The  projection-test  enables 
us  to  determine  whether  the  retina  is  the  seat  of  a  gross 
lesion,  such  as  detachment,  occlusion  of  its  vessels,  etc. ; 
or  if,  for  example,  a  tumor  of  the  choroid  is  present. 

The  function  of  the  retina  and  of  the  optic  nerve  is 
further  determined  by  testing  the  pupillary  reaction,  which 
incidentally  shows  whether  any  synechia  are  present. 
Although  the  latter  do  not  render  the  operation  impos- 
sible, they  diminish  the  chances  for  success  because  they 
are  often  associated  with  disease  of  the  vitreous. 

As  it  is  impossible  in  most  cases,  if  the  cataract  is  com- 
plete before  the  patient  is  seen,  to  find  out  whether  the 
posterior  segment  of  the  eye  is  in  good  condition — as  it 
ought  to  be  if  the  cataract  operation  is  to  be  successful — 
it  is  very  important  that  the  practising  physician  who 
recognizes,  or  at  least  suspects,  beginning  cataract  should 
send  his  patient  at  once  to  the  oculist  who  is  to  operate 
later  on,  so  as  to  enable  the  latter  to  satisfy  himself  that 
the  lens  is  still  tolerably  transparent,  that  the  eye  is  sound, 
and,  in  short,  to  enable  him  to  get  better  acquainted  with 
the  eye.     This  is  often  of  the  utmost  value. 

I  wish  to  state  emphatically,  however,  that  it  is  both 
inhuman  and  unwise  for  either  a  general  practitioner  or  a 
specialist  to  mention  cataract  and  operation  to  a  patient 
before  the  cataract  has  reached  the  stage  when  an  opera- 
tion will  soon  be  required ;  for  nobody  likes  to  be  told 
that  he  has  a  cataract  (our  excellent  statistics  notwith- 
standing), and  most  people  are  greatly  alarmed  by  the 
information.     Besides,  if  the  individual  is  very  old  and 


OPERATION  FOR  CATARACT.  95 

dies  before  operation  becomes  necessary,  the  physician 
will  have  embittered  his  declining  days  unnecessarily  by 
the  premature  announcement.  In  the  same  way  it  is  bad 
practice  to  mention  the  question  of  operation  until  it  has 
been  definitely  determined  that  the  cataract  can  be  suc- 
cessfully extracted. 

3.  Bodily  (General)  Condition  of  the  Patient. — Another 
important  condition  for  a  successful  operation  is  that  the 
general  bodily  condition  of  the  patient  be  satisfactory. 
Extreme  age  is  no  contra-indication  to  a  cataract  opera- 
tion if  the  patient's  strength  is  fairly  good,  although 
patients  and  their  friends  usually  think  otherwise.  Idiocy, 
minor  degrees  of  epilepsy,  and  deaf-mutism  do  not  con- 
tra-indicate  the  operation  ;  on  the  contrary,  those  afflicted 
with  the  latter  misfortune  should  be  operated  upon  as 
early  as  possible,  and  are  usually  most  grateful  for  the 
improvement  in  their  general  condition  thus  brought 
about. 

The  operation  is  not  rendered  impossible  by  diabetes 
and  albuminuria,  unless  the  diseases  mentioned  are  far 
advanced  ;  but  under  such  circumstances  special  caution 
is  required  and  the  diet  must  be  suitably  regulated  in 
some  cases  for  some  time  before  the  operation. 

On  the  other  hand,  suppurating  processes  of  any  kind 
in  the  body — leg  ulcers,  eczema,  and  the  like — must  be 
regarded  as  strict  contra-indications  so  long  as  they  are 
present.  If  they  can  not  be  cured,  the  diseased  portion 
must  at  least  be  rendered  innocuous  by  covering  it  with 
an  antiseptic  bandage  during  the  entire  time  the  eyes  are 
under  treatment.  It  is  absolutely  indispensable  to  sur- 
round the  eye  with  special  care  before  and  after  the 
operation  in  such  cases. 

The  conditions  for  a  cataract  operation,  so  far  as  the 
eye  itself  is  concerned,  can  be  deduced  in  part  from 
what  has  been  said  and  in  part  will  be  discussed  in  con- 
nection with  methods  of  operation. 

If  both  eyes  are  the  seat  of  cataracts  that  have  reached 
maturity,  it  is  not  advisable  to  operate  on  both  cataracts 


96  OPERATIONS  ON  THE  EYE. 

at  the  same  time,  because  if  any  unfortunate  complication, 
such  as  wound-infection  during  the  operation,  delirium 
tremens,  diphtheria  or  erysipelas  should  ensue,  both  eyes 
might  be  lost.  It  is  better  to  defer  operation  on  the 
second  eye  until  after  the  wound  in  the  first  has  healed, 
and,  in  the  case  of  old  persons,  until  after  the  patient  has 
completely  recovered  from  the  first  operation. 

Is  it  proper  to  operate  on  an  eye  with  a  ripe  cataract 
when  vision  is  perfectly  good  in  the  other  eye?  The 
answer  to  this  question  is  that  it  is  proper  to  remove 
cataract  of  this  kind  only  when  it  has  become  completely 
ripe  and  is  in  no  danger  of  becoming  over-ripe.  Under 
such  circumstances,  however,  the  patient  often  exhibits 
very  little  gratitude  for  having  obtained  vision  Avith  his 
cataractous  eye,  and  occasionally  he  even  complains  that 
the  vision  of  the  operated  eye  disturbs  that  of  the  sound 
eye.  It  is  therefore  well  to  explain  the  state  of  the  case 
to  him  carefully  beforehand  and  to  tell  him  that  the  eye 
which  is  to  be  operated  upon  will  only  be  used  to  a 
moderate  degree,  and,  in  a  sense,  represents  a  reserve  eye 
in  case  the  other  should  at  any  time  become  blind  from 
cataract.  He  should  be  told  that  he  really  would  not 
need  cataract  glasses  after  recovery  ;  but  practically  it  is 
better  to  give  him  cataract  glasses  nevertheless,  in  order 
to  enable  him  to  convince  himself  that  he  can  see  with 
the  eye ;  otherwise  he  will  think  the  operation  has  been 
unsuccessful. 

The  important  and  often  difficult  question,  when  may 
or  shall  a  cataract  be  operated  upon  before  it  is  ripe  has 
been  largely  answered  in  the  foregoing  pages.  It  may  be 
well,  however,  ,to  recapitulate.  There  is  no  doubt  that 
nowadays,  thanks  to  the  improvement  in  the  treatment  of 
wounds,  we  need  not  hesitate  as  much  as  formerly  to 
operate  on  unripe  cataracts  when  it  is  necessary.  It  would 
not  be  right  to  adhere  to  the  former  practice,  which  at 
that  time  was  perfectly  justifiable,  to  make  patients  wait, 
sometimes  until  they  depart  for  a  better  world,  for  com- 
plete ripening  of  the  cataract  and  operation.      It  must 


OPERATION  FOR   CATARACT.  97 

always  be  clearly  kept  in  mind  that  an  operation  on  a 
cataract  which  is  actually — not  only  apparently — unripe 
involves  certain  dangers,  the  least  of  which  is  a  tedious 
recovery.  The  last-mentioned  fact  must  be  clearly  placed 
before  anyone  with  a  cataract  of  this  kind,  and  it  must 
be  explained  to  him  beforehand  that  a  secondary  opera- 
tion will  probably  have  to  be  performed.  If  in  the 
end  it  turns  out  that  the  latter  is  unnecessary,  it  is  all 
the  better. 

My  experience  has  not  taught  me  that  cataract,  whether 
completely  or  only  partially  opaque,  can  be  extraced  with 
the  same  success  after  the  sixtieth  year  of  life.  When 
the  opacity  of  the  cataract  is  incomplete,  it  often  requires 
weeks  or  even  months  for  the  remains  to  be  absorbed.  It 
is  true  that  even  in  these  cases  vision  may  eventually  be 
quite  good ;  a  question  that  will  be  referred  to  later. 

When  shall  an  operation  for  cataract  be  preceded  by  an 
iridectomy  ? 

This  question,  which  will  be  touched  upon  again  in  the 
course  of  this  work,  may  be  answered  in  a  general  way  by 
saying  that  on  general  principles  iridectomy  is  to  be  avoided 
in  operating  on  cataract  and  is  to  be  resorted  to  only  when 
there  are  strong  reasons  for  doing  so. 

It  will  probably  be  generally  conceded  at  the  present 
time  that  in  all  cases  of  juvenile  cataract,  including  the 
lamellar  form,  and  in  all  cases  up  to  the  fortieth  or  forty- 
fifth  year  of  life,  especially  in  female  patients,  iridectomy 
can  in  almost  every  instance  be  avoided  and  must  be 
avoided.  Even  if  the  tension  increases  while  a  cataract 
of  this  kind  is  under  treatment,  iridectomy  is  not  always 
necessary  at  this  age ;  for  the  increased  tension  may  be 
corrected  by  corneal  puncture  or  possibly  by  a  sclerotomy. 

At  this  time  of  life  the  question  of  appearance  must 
be  considered  by  the  operator,  because  at  this  age  the  eyes 
are  generally  held  wide  open,  while  in  old  persons,  owing 
to  the  loss  of  fat  in  the  orbit,  the  upper  lid  usually  hangs 
down  over  and,  as  a  rule,  covers  the  upper  half  of  the 
cornea,  so  that  one  has  to  raise  the  eyelid  with  the  finger 
7 


98  OPERATIONS  ON  THE  EYE. 

in  old  people  to  find  out  whether  an  iridectomy  has  been 
performed. 

Another  reason  why  iridectomy  is  less  urgent  in  earlier 
life,  up  to  the  age  of  forty  or  forty-five,  is  that  the 
nucleus  of  the  cataract  is  not  so  large ;  hence  its  delivery 
is  easier  and  not  so  severe  on  the  iris,  as  is  the  case  later  on. 

Opinions  differ  as  to  whether  in  the  case  of  true  senile 
cataract  the  operation  should  or  should  not  be  preceded 
by  iridectomy.  It  may  be  remarked  in  general  that, 
although  an  operator  may  on  principle  avoid  iridectomy, 
he  will  nevertheless  be  compelled  from  time  to  time  to 
resort  to  the  operation,  and  that  it  is  better  to  do  so  when- 
ever the  iris  is  at  all  slow  to  return  to  the  anterior  cham- 
ber after  the  delivery  of  the  cataract,  and  there  is  corre- 
sponding failure  of  the  pupil  to  contract.  It  is  impossible 
to  know  beforehand  how  the  iris  Mill  act.  Individuals 
differ  in  this  respect,  and  it  has  often  been  observed  that 
if  the  iris  returns  readily  in  one  eye  it  will  do  the  same 
in  the  other  if  the  latter  is  operated  upon  later ;  and,  con- 
versely, if  the  iris  shows  flaccidity  in  the  first  eye,  it  will 
do  the  same  thing  in  the  second  eye.  It  is  not  advisable 
to  bring  about  contraction  of  the  pupil  beforehand  by  in- 
stilling physostigmin,  because  the  contraction  of  the  pupil 
may  interfere  with  the  ready  escape  of  the  cataract,  with 
the  result  that  a  good  deal  of  cortical  matter  is  stripped 
off  and  remains  behind  the  iris. 

In  the  case  of  old  and  feeble  persons  who  must  not  be 
kept  in  bed  for  any  length  of  time,  because  they  would 
lose  their  appetite  altogether  and  might  develop  hypostatic 
pneumonia  from  the  continued  recumbent  posture,  it  is 
more  advisable,  as  a  rule,  to  excise  the  iris,  for  by  doing 
so  it  is  quite  possible  to  allow  the  patient  to  get  up  and 
walk  about  twenty-four  hours  after  the  operation,  without 
the  danger  of  prolapse  of  the  iris. 

In  another  class  of  patients,  who,  for  other  reasons, 
such  as,  for  example,  occasional  severe  attacks  of  cough- 
ing or  sneezing,  great  nervous  excitement,  nervous  dis- 
tress on  account  of  heart  trouble  and  the  like,  are  not 


OPERATION  FOR  CATARACT.  99 

likely  to  keep  quiet  for  twenty-four  to  forty-eight  hours, 
it  is  advisable  to  perform  an  iridectomy  before  extracting 
the  cataract.  In  many  cases  of  this  kind  and  whenever 
a  complication  before  or  after  the  operation  is  imminent, 
such,  for  example,  as  an  escape  of  vitreous  by  reason  of 
the  patient's  unmanageableness  or  idiocy,  abnormal  con- 
ditions of  the  eye — such  as  liquefaction  of  the  vitreous 
from  myopia  and  the  like — it  is  always  well  to  have  a  pre- 
liminary iridectomy. 

In  weighing  the  reasons  for  and  against  iridectomy  in 
operations  for  senile  cataract  it  should  be  mentioned  that 
it  is  of  no  importance  whatever,  so  far  as  the  patient's 
ultimate  visual  power  is  concerned,  whether  the  pupil 
remains  round  or  not.  In  either  case  vision  may  be  nor- 
mal or  practically  normal,  provided  the  pupillary  region 
is  free  from  the  remains  of  cataract.  Owing  to  this 
necessity  of  keeping  the  pupillary  region  absolutely  clear, 
secondary  cataract  operations  are  somewhat  more  fre- 
quently required  after  the  simple  one,  that  is,  one  with- 
out iridectomy,  than  after  an  operation  combined  with  iri- 
dectomy, because  the  remains  of  the  cataract  can  be  better 
stripped  out  in  the  latter  case  than  when  the  iris  remains 
intact  and  therefore  hinders  the  escape  of  the  soft  cortical 
masses.  This  is  not  a  very  important  factor,  however, 
because  secondary  operations  have  to  be  resorted  to  often 
enough  after  combined  extraction  if  the  operator  hopes  to 
secure  perfect  vision. 

It  has  been  objected  to  by  those  who  advocate  the 
simple  operation  that  the  increased  amount  of  light 
admitted  to  the  eye,  as  the  result  of  the  iridectomy,  may 
be  a  disturbing  factor.  It  is  to  be  remarked,  however, 
that  in  the  case  of  old  persons  the  upper  lid  generally 
covers  the  iridectomy  and  prevents  the  light  from  enter- 
ing through  the  coloboma.  On  the  other  hand,  when  the 
upper  lid  does  not  hang  so  low,  as,  for  example,  when  the 
eyes  are  somewhat  more  prominent,  it  is  quite  true  that 
the  iridectomy-gap  is  not  screened  against  the  excess  of 
light,  and  that  an  increased  amount  of  light  enters  the 


100  OPERATIONS  ON  THE  EYE. 

eye  and  may  blind  the  patient  and  cause  him  to  see  red — 
erythropsia.  The  latter  phenomenon  is  due  to  the  fact 
that  when  an  eye,  particularly  one  that  is  deprived  of  its 
lens,  is  exposed  to  strong  light  for  some  time,  the  retina 
gets  into  a  condition  of  excessive  irritation  ;  and  when 
the  patient  enters  a  dark  place  all  bright  objects  for  a 
time  appear  to  be  colored  a  bright  red,  which  greatly 
frightens  the  patient  and  causes  him  to  think  that  a  hem- 
orrhage has  occurred.  It  appears  from  the  investigations 
of  Fuchs  and  others  that  the  ultraviolet  light  rays  are 
chiefly  concerned  in  producing  this  effect  on  the  retina 
and  that  they  may  cause  erythropsia  in  the  normal  eye, 
as,  for  example,  after  a  long  period  of  snow-blindness  on 
high  mountains.  As  the  lens  has  a  high  absorption  for 
chemical  light  rays  and  keeps  them  away  from  the  retina, 
eyes  with  aphakia  are  more  liable  to  erythropsia  than  those 
which  still  possess  a  lens. 

If,  therefore,  the  upper  part  of  the  iris  is  not  covered 
by  the  lid,  it  is  better  to  leave  the  iris  intact  when  opera- 
ting for  cataract. 

It  is  not  true,  however,  that  simple  cataract  extraction 
without  iridectomy  is  less  dangerous  and  less  apt  to  be 
followed  by  wound  infection  because  the  traumatism  to 
the  eye  is  somewhat  less  extensive. 

First  of  all,  the  simple  operation  has  the  disadvantage 
that  if,  during  the  night  after  the  operation  or  even  later, 
the  wound  suddenly  opens,  the  iris  may  be  washed  into 
the  wound  by  the  aqueous  humor  and  a  prolapse  of  the 
iris  may  thus  be  produced,  causing  distortion  of  the  pupil 
upward  and  disfiguring  the  eye  and  interfering  with  the 
regular  progress  of  recovery.  It  is  anything  but  pleasant 
under  such  circumstances  to  be  forced  to  operate  again  ; 
for  there  is  no  choice  and  the  prolapsed  portion  of  the 
iris  must  be  removed  absolutely.  This  point  will  be 
referred  to  later. 

On  the  other  hand,  it  is  possible,  even  when  the  opera- 
tion for  cataract  is  preceded  by  iridectomy  and  especially 
if  the  wound  is  slow  to  heal  and  frequently  reopens,  for 


OPERATION  FOR  CATARACT.  .  101 

the  iris  to  slip  into  the  wound  or  to  be  washed  into  it  by 
the  aqueous  humor.  As  a  rule  this  happens  only  on  one 
side  of  the  coloboma.  But  the  accident  is  not  often 
observed  and  is  usually  mild  in  degree. 

It  will  be  well,  on  the  whole,  to  decide  this  question  of 
iridectomy  chiefly  by  individual  conditions  and  to  avoid 
routine  methods. 

Under  what  circumstances  may  general  anesthesia  be 
employed  for  cataract  operation  ? 

In  answering  this  question  it  is  to  be  remembered  that 
the  eyeball  is,  as  a  rule,  rotated  upward  during  the  anes- 
thesia, especially  if  it  is  not  very  profound,  and  thus 
makes  it  difficult  to  place  the  incision  at  the  upper  border 
of  the  cornea,  which  is  justly  considered  the  preferable 
site.  It  is  not  always  easy  in  general  anesthesia  to  rotate 
the  eyeball  downward  with  the  forceps  without  causing 
a  dangerous  gaping  of  the  wound. 

Another  disadvantage  of  general  anesthesia  is  the  vom- 
iting that  frequently  follows,  as  it  is  apt  to  interfere  with 
closure  of  the  wound,  and  in  old  persons  with  friable 
vessels  may  cause  intra-ocular  hemorrhage. 

Finally,  general  anesthesia  always  implies  a  certain 
degree  of  danger  to  life. 

Cataract  operations,  to  begin  with,  are  not  very  painful, 
and  with  the  proper  use  of  cocain  can  be  rendered  bear- 
able even  to  the  most  sensitive  patient,  so  that,  for  these 
reasons  and  the  above  considerations  as  well,  general  anes- 
thesia should  be  practically  abandoned  in  the  case  of  old 
persons,  and  if  employed  at  all  should  be  reserved  for 
patients  who,  on  account  of  idiocy  or  absolute  inability 
to  control  themselves,  offer  no  guarantee  that  they  will 
conduct  themselves  properly  during  the  operation.  In 
such  cases  it  may  be  advisable  to  extract  the  cataract  from 
below  if  the  upward  rotation  of  the  eyes  is  very  marked. 
In  operating  on  children,  chloroform  is  always  necessary 
if,  owing  to  great  restlessness  and  excitement  on  the  part 
of  the  little  patient,  it  is  impossible  to  perform  the  opera- 
tion properly,  and  especially  when  there  is  danger  of  tear- 


102  OPERATIONS  ON  THE  EYE. 

ing  the  zonule  of  Zinn  and  thus  allowing  the  vitreous  to 
enter  the  wound.  In  the  ease  of  very  small  children  only 
a  small  quantity  of  chloroform  is  required  to  keep  them 
quiet  during  the  brief  time  occupied.  It  is  often  possible 
by  speaking  to  the  child  kindly,  and,  especially  if  one  has 
good  assistants,  to  control  the  situation  with  cocain. 

Having  thus  discussed  in  a  general  way  the  necessary 
conditions  for  a  cataract  operation  and  the  preliminary 
examinations,  I  shall  turn  my  attention  to  the  operation 
itself  as  it  is  to  be  performed  in  the  various  forms  of 
cataract,  and  shall  incidentally  discuss  various  special 
aspects  of  the  question,  including  the  after-treatment. 
Beginning  with  the  simpler  procedure  which  suffices  for 
removing  a  cataract  in  the  case  of  children,  we  proceed  to 
discuss 

(a)  The  Operation  for  the  Removal  of  Total  Juvenile 
Cataract. 

By  this  term  is  meant  a  cataract  which  is  noticed  soon 
after  birth  or  perhaps  somewhat  later,  and  is  usually 
brought  to  the  physician  for  treatment  early  because  the 
gray  color  in  the  pupil  is  noticed  by  the  patient's  family. 
This  form  of  cataract  is  usually  bilateral  and  much  more 
rare  than  senile  cataract. 

Juvenile  cataract  is  especially  amenable  to  treatment  by 
simple  discission,  a  method  which,  owing  to  its  simplicity, 
can  be  used  with  little  children.  The  indication  is  to  re- 
move these  cataracts  as  early  as  possible,  so  as  to  enable  the 
retina  to  receive  distinct  images  as  soon  as  the  child  begins 
to  use  its  eyes,  and  thus  prevent  the  development  of  the 
form  of  defective  vision  which  has  been  attributed  to  fail- 
ure to  use  the  retina  during  the  period  of  development 
(amblyopia  exanopsia),  and  which  may  give  rise  to  nystag- 
mus— i.  e.j  irregular  action  of  the  eye-muscles — explain- 
able on  the  assumption  that  the  complicated  mechanism  of 
the  ocular  muscles  is  not  properly  regulated  by  the  forma- 
tion of  distinct  retinal  images,  and  therefore  fails  to  de- 
velop properly. 


REMOVAL   OF  TOTAL  JUVENILE  CATARACT.    103 

Nevertheless  it  is  not  advisable  to  operate  on  these  cata- 
racts too  early — i.  e.,  before  the  end  of  the  first  or  second 
year  of  life — because  it  sometimes  happens  that,  owing  to 
prolapse  of  the  cataract  into  the  anterior  chamber,  incision 
of  the  cornea  and  the  removal  of  part  of  the  cataractized 
masses  become  necessary  after  discission  has  been  per- 
formed. This  complicates  the  operative  treatment  and 
requires  bandages  and  sometimes  rest,  measures  that  are 
difficult  to  carry  out  in  the  case  of  a  very  small  child. 

On  the  other  hand,  the  operation  must  not  be  delayed 
too  long,  because  otherwise  a  cataract  of  this  kind  becomes 
over-ripe,  contracts,  and  then  requires  the  same  treatment 
as  a  senile,  membranous  cataract,  which  is  similar  to  the 
treatment  of  dense  secondary  cataract  (to  be  discussed 
later),  and  which  may  be  attended  with  some  difficulties. 

Before  beginning  the  operation,  a  careful  examination 
must  be  made  to  determine  whether  the  cataract  is  simple 
or  complicated,  and  particularly  whether  there  are  any 
synechia? — i.  c,  traces  of  an  antecedent  or  still  active 
iritis.  If  there  are  synechia? — which  may  not  be  dis- 
tinctly visible  until  the  pupil  has  been  dilated  with  horno- 
tropin  or  atropin — the  prognosis  is  dubious,  because  these 
are  generally  cases  of  congenital  syphilis.  This  fact 
should  be  made  clear  to  the  family  beforehand,  for  the 
reason  that  in  this  disease  other  alterations  are  often 
present  in  the  deeper  structures  of  the  eye  or  may  make 
their  appearance  after  the  operation  and  endanger  the  eye- 
sight. On  general  principles  it  is  wiser  in  the  case  of 
cataract  in  very  small  children,  even  when  they  are  not 
complicated,  to  maintain  a  certain  reserve  in  regard  to  the 
result  of  the  operation.  There  are  cases  which  never 
attain  more  than  a  moderate  visual  power,  even  when  re- 
sulting successfully,  a  condition  for  which  it  is  sometimes 
impossible  to  discover  a  cause. 

The  preparations  for  discission  are  simple.  As  the 
operative  wound  is  a  mere  perforation  and  is  therefore  a 
comparatively  trivial  interference,  the  cleansing  of  the 
operative  field  need  not  be  so  rigorous.     After  the  pupil 


104 


OPERATIONS  ON  THE  EYE. 


has  been  dilated  with  atropin  and  a  few  drops  of  a  3  per 
cent,  solution  of  cocain  have  been  introduced  into  the  eye, 
the  skin  of  the  lids  and  surrounding  portions  is  cleansed 
with  soap  and  warm  water,  and  then  with  bichlorid  solu- 
tion of  1  :  1000,  after  which  the  conjunctival  sac  is  washed 
out  with  a  bichlorid  solution  of  1  :  5000  or  with  sterile 
salt  solution.  The  operation  is  usually  performed  without 
anesthesia.  The  speculum  (Fig.  10),  is  introduced  or  an 
assistant  holds  the  lids  apart,  the  operator  seizes  the  bulb 
with  the  fixation  forceps  (Fig.  21)  at  a  point  to  the  nasal 
side  of  the  cornea,  and  with  a  discission  needle  (Fig.  56) 
or  a  capsule  knife  (Fig.  58)  pierces  the  cornea  at  a  point  a 
little  below  the  horizontal  meridian  and  3  mm.  from  the 


Fig.  3.— Division  of  the 
anterior  capsule  of  the 
lens  with  Bowman's  dis- 
cission needle. 


Fig.  4.— Linear  incision 
through  the  cornea  with 
the  keratome. 


Fig.  5.— Flat 
curved  incision. 


temporal  border  of  the  membrane,  carrying  the  instru- 
ment a  little  beyond  the  center  of  the  pupil.  [The  needle 
may  be  entered  just  external  to  the  limbus. — Ed.]  After 
the  lens  has  been  entered,  an  opening  is  made  with  the 
point  of  the  needle  in  the  capsule  of  the  lens,  4  to  5  mm.  in 
length,  and  running  from  above  downward  (Fig.  3) ;  the 
needle  is  then  rotated  about  its  long  axis  and  at  the  same 
time  slightly  withdrawn,  a  short  transverse  incision  is 
made,  and,  after  the  needle  has  been  rotated  back  into  its 
original  position,  it  is  quickly  removed,  so  as  to  prevent 
the  escape  of  any  aqueous  humor.  A  little  cotton  and  a  few 
strips  of  adhesive  plaster  are  always  necessary  for  a  dress- 
ing, and  during  the  first  two  days  the  child's  arms  must, 


REMOVAL   OF  TOTAL  JUVENILE  CATARACT.    105 

as  a  rule,  be  bound  to  its  sides  to  prevent  its  handling  the 
dressings. 

The  after-treatment  consists  in  carefully  looking  after  the 
dressing  and  keeping  the  pupil  dilated  by  instilling  from 
1  to  2  drops  of  atropin  solution  per  day.  The  eye  must 
be  kept  under  close  supervision  on  account  of  the  danger 
of  increased  tension,  which  would  manifest  itself  by  haziness 
of  the  surface  of  the  cornea.  If  the  child  cries  out  and  cL  >ses 
the  eyes  forcibly  when  an  attempt  is  made  to  determine 
th'e  intra-ocular  tension  by  palpation,  it  must  be  brought 
slightly  under  the  influence  of  an  anesthetic.  If  the 
tension  rises  on  account  of  prolapse  of  cataractous  ma- 
terial the  first  thing  to  do  is  to  diminish  the  atropin,  and, 
if  that  fails  to  correct  the  trouble,  an  incision  is  made  in 
the  anterior  chamber,  under  full  anesthesia,  if  the  child  is 
unruly. 

For  this  purpose  a  keratome  instead  of  a  needle  is  in- 
troduced into  the  anterior  chamber  in  the  same  way  as  for 
discission.  The  instrument  is  best  introduced  in  the 
temporal  portion  of  the  cornea,  between  the  margin  and 
the  center,  so  as  to  make  a  vertical  incision  from  4  to  6  mm. 
in  length,  the  extremities  being  at  equal  distances  from 
the  center  of  the  cornea  (Fig.  4).  After  the  lens  has  been 
withdrawn,  the  periphery  of  the  wound  is  depressed  some- 
what with  the  spatula  (Fig.  30),  so  as  to  make  the  wound 
gape  and  cause  the  escape  of  the  cataractous  mass.  If  the 
latter  is  tough  and  slow  to  escape,  the  spatula  is  intro- 
duced a  distance  of  4  to  5  mm.  into  the  anterior  chamber 
and  into  the  cataractous  mass,  the  periphery  of  the  wTound 
is  pushed  back,  and  the  spatula  rotated  around  the  long 
axis  of  its  handle  from  one  side  to  the  other  to  stir  up  the 
cataractous  masses.  By  the  aid  of  this  manouver  it  is 
possible  to  evacuate  a  considerable  quantity  of  lenticular 
masses  without  doing  any  injury,  even  when  they  are  quite 
tough.  If  necessary,  the  evacuation  may  be  assisted  by 
exerting  moderate  pressure  on  the  globe  at  the  same  time 
with  the  fixation-forceps. 

The  anterior  chamber  may  also  be  opened  at  the  tern- 


106  OPERATIONS  ON  THE  EYE. 

poral,  lower,  or  upper  border  of  the  cornea  instead  of 
between  the  border  and  the  center  (Fig.  5).  If  during 
the  evacuation  of  the  cataract  the  iris  is  forced  into  the 
wound,  the  surgeon  must  take  care  not  to  leave  it  there, 
but  must  replace  it  with  the  aid  of  the  spatula. 

The  operation  of  opening  the  anterior  chamber  by  means  of  the 
incisions  shown  in  Figs.  4  and  5  is  also  called  simple  linear  extraction, 
bnt  the  term  is  not  appropriate  for  most  of  these  incisions.  A  true 
linear  incision  through  the  cornea  must  occupy  the  plane  of  one  of  its 
meridians — that  is,  a  plane  which  passes  through  the  center  of  the 
curvature  of  the  cornea.  Such  an  incision  would  necessitate  intro- 
ducing the  keratome  practically  at  a  right  angle  and  aiming  directly  at 
the  said  center  of  curvature.  But  such  a  method  of  introducing  the 
lancet  would  endanger  the  posterior  capsule  of  the  lens.  A  linear 
incision  might  resemble  the  flat-curved  incision  shown  in  Fig.  4 ;  the 
line  shown  in  Fig.  5  passing  transversely  over  the  cornea  would  also 
represent  a  linear  incision.  As  a  rule,  however,  the  keratome  is  intro- 
duced into  the  anterior  chamber  in  such  a  way  that  the  wound  coin- 
cides with  a  parallel  of  the  cornea,  and  therefore  represents  a  flat 
incision  or  curved  incision  with  variable  degrees  of  convexity,  as,  for 
example,  the  incision  at  the  lower  border  of  the  cornea  shown  in  Fig.  5. 

This  method  of  removing  portions  of  the  cataract  also 
requires  great  care  to  prevent  rupture  of  the  zonula  or 
laceration  of  the  posterior  capsule  and  the  escape  of 
vitreous  into  the  wound.  This  unfortunate  accident  may- 
even  folloAV  primary  incision  if  the  operator  is  not  careful 
to  avoid  lateral  traction  of  the  lens  in  performing  the 
operation.  If  the  vitreous  appears  in  the  corneal  wound 
in  the  form  of  a  transparent  bead,  the  operation  must  be 
terminated  at  once  and  a  dressing  applied.  If  this  is 
done,  a  small  quantity  of  vitreous  may  return  of  its  own 
accord. 

After  the  cataract  has  been  removed  in  this  way  a 
heavy  dressing  of  cotton,  adhesive-plaster  strips,  and  a 
roller  bandage,  usually  a  double  one,  must  be  worn  for 
two  days.  At  the  end  of  every  twenty-four  hours  the 
surgeon  must  determine  whether  atropin  is  necessary  to 
keep  the  pupil  dilated,  and  how  much  is  required.  In 
children,  who  always  try  to  rub  their  eyes,  the  eye  that 
has  been  operated  upon  must  be  kept  well  bandaged  for  at 
least  a  week. 


REMOVAL   OF  TOTAL  JUVENILE  CATARACT.    107 

If  the  child  is  somewhat  older  and  has  the  sense  to 
submit  to  rest  and  the  application  of  a  bandage,  the  treat- 
ment by  discission  may  be  abandoned  in  favor  of  the 
senile  linear  extraction — i.  e.}  extraction  of  the  cataract 
through  an  incision  like  those  shown  in  Figs.  4  and  5. 

Without  previous  dilatation  of  the  pupil  by  atropin 
the  eye  is  cocainized,  the  lids  and  surrounding  skin 
cleansed  with  soap  and  bichlorid  solution,  and,  after  the 
conjunctival  sac  has  been  flushed  out  with  a  1  :  5000  solu- 
tion of  bichlorid  or  with  sterile  salt  solution,  the  stop- 
speculum  is  applied  and  the  cornea  at  once  opened  by 
means  of  one  or  the  other  above-mentioned  incisions. 
The  keratome  may  also  be  introduced  from  above ;  but  as 
a  rule  it  will  be  found  most  convenient  to  introduce  the 
instrument  on  the  temporal  side,  as  shown  in  Fig.  4,  the 
globe  being  steadied  by  seizing  the  conjunctiva  with  the 
fixation-forceps  near  the  corneal  margin,  at  a  point  oppo- 
site the  entrance  to  the  wound,  as  shown  in  Plate  6.  In 
carrying  the  keratome  forward  the  point  must  always  be 
directed  toward  the  axis  of  the  eye.  The  opening  of  the 
anterior  capsule  may  be  effected  by  introducing  the  kera- 
tome into  the  lens  at  once  or,  better,  by  withdrawing  the 
instrument  after  the  corneal  incision,  which  should  be 
5  to  6  mm.  in  length,  has  been  made,  and  afterward  opening 
the  capsule  by  a  fairly  liberal  incision  with  a  cystotome 
(Fig.  40),  as  will  be  more  accurately  described  later  in 
connection  with  operations  on  senile  cataracts.  In  this 
procedure  also  great  care  must  be  exercised  to  avoid  lateral 
dislocation  of  the  lens,  so  as  not  to  lacerate  the  zonule  of 
Zinn.  As  a  rule,  the  opening  of  the  anterior  capsule  is  at 
once  followed  by  the  escape  of  part  of  the  cataract  into 
the  anterior  chamber.  The  next  step  consists  in  evacuating 
the  entire  cataractous  mass  with  the  spatula,  as  has 
already  been  explained.  Small  remnants  may  be  left  to 
be  absorbed.  The  after-treatment  is  the  same  as  that 
of  incision  following  discission. 


108  OPERATIONS  ON  THE  EYE. 

(b)   Operation  for  Total  Soft  Cataract  of  Adults. 

The  cataract  is  removed  in  the  manner  just  described 
by  means  of  a  corneal  incision  ("  simple  linear  extrac- 
tion ")  whenever  the  age  of  the  patient  and  the  appear- 
ance of  the  cataract  are  such  as  to  make  it  probable  that 
the  cataract  does  not  contain  a  nucleus  or  a  small  one. 
The  presence  of  a  nucleus  can  sometimes  be  recognized 
under  strong  lateral  illumination  by  the  presence  of  a 
denser  opacity  in  the  central  portion  of  the  lens,  particu- 
larly in  patients  over  thirty-five  years  of  age.  If  the 
presence  of  a  nucleus  is  demonstrated,  or  the  age  of  the 
patient  is  such  as  to  render  its  presence  probable,  a  curved, 
and  correspondingly  larger,  incision  is  made  at  the  edge 
of  the  cornea,  either  with  a  keratome  or  with  a  Gräfe 
cataract-knife.  The  operation  is  exactly  like  that  for 
senile  cataract  without  iridectomy,  to  which  the  reader  is 
accordingly  referred. 

Soft  cataracts  in  middle-aged  patients,  particularly  in  women,  are 
sometimes  complicated  with  iritic  deposits  on  the  posterior  wall  of  the 
cornea,  with  synechiae,  and  without  the  eye  exhibiting  any  other  dis- 
ease— no  redness  or  irritation.  Such  a  condition  is,  according  to  my 
experience,  no  contra-indication  to  the  operation.  As  a  rule  the 
deposits  disappear  after  the  operation. 

(c)   Operation  for  Traumatic  Cataract. 

Up  to  the  age  of  thirty-five  to  forty  years,  the  period 
when  nucleus-formation  begins  to  be  marked,  this  opera- 
tion is  also  performed  according  to  the  method  described 
in  the  preceding  paragraph — i.e.,  the  cataract  is  removed 
through  a  corneal  incision  of  varying  size. 

If  the  anterior  capsule  has  been  opened  by  the  injury 
and  the  wound  lias  failed  to  close,  causing  the  escape  of 
cataractous  masses,  exactly  as  after  a  discission  when  the 
operation  is  performed  on  a  lens  that  is  not  opaque  or  only 
partially  so,  nothing  more  is  required  except  an  incision 
to  the  anterior  chamber.  If,  on  the  other  hand,  the 
anterior  capsule  lias  only  sustained  a  slight  injury  and  the 
wound   has  closed,  a  form  of  cataract  in   every  respect 


OPERATION  FOR   TRAUMATIC  CATARACT.        109 

resembling  ordinary  spontaneous  cataract  may  develop, 
and  the  operator  will  be  forced  to  open  the  anterior 
capsule.  The  same  thing  often  happens  when  a  small 
foreign  body  perforates  the  lens  completely  or  becomes 
embedded  in  the  posterior  capsule  without  injuring  the 
structure. 

When  a  splinter  has  passed  completely  through  the 
lens,  as  not  infrequently  happens,  total  cataract,  as  a  rule, 
develops  sooner  or  later.  In  very  rare  instances — I  have 
personally  observed  such  a  case — the  lens  remains  clear. 
In  operating  on  such  a  lens  after  it  has  become  completely 
opaque,  much  greater  care  is  required  than  in  cases  in 
which  the  posterior  capsule  is  intact ;  for  the  wound  of 
the  posterior  capsule,  even  though  it  may  be  small  and 
may  have  existed  for  some  time,  so  as  to  make  it  probable 
that  cicatrization  has  taken  place,  is  apt  to  re-open — ac- 
cording to  my  experience — and  allow  the  vitreous  to 
escape  into  the  wound,  thus  bringing  about  a  most  unde- 
sirable complication.  It  seems  that  under  certain  circum- 
stances the  wound  in  the  posterior  capsule  enlarges,  and 
even  when  the  original  opening  is  small,  the  prolapse  of 
vitreous  may  be  quite  considerable. 

In  order  to  minimize  this  danger  it  is  advisable  to  keep 
the  eye  under  the  influence  of  cocain  for  some  time  before 
the  operation — that  is,  to  instill  1  drop  of  a  3  per  cent, 
solution  of  cocain  every  five  minutes  for  one-half  hour, 
because  the  intra-ocular  tension  is  thereby  diminished.  It 
is  also  advisable,  as  in  every  case  when  an  escape  of 
vitreous  is  to  be  feared,  to  tell  the  patient,  during  the 
operation,  to  keep  his  eye  directed  straight  forward — that 
is,  in  the  primary  position,  and  to  rotate  it  as  little  as 
possible  to  the  side  or  upward,  because  rotation  of  the 
eye,  by  increasing  the  pressure  of  the  external  eye-muscles 
which  are  put  on  the  stretch,  causes  an  increase  in  the 
intra-ocular  tension  and  brings  with  it  the  danger  of 
escape  of  the  vitreous.  For  this  reason  a  cataract  of  this 
kind  is  best  extracted  through  an  incision  in  the  temporal 
or  lower  half  of  the  cornea. 


110  OPERATIONS  ON  THE  EYE. 

In  these  cases  there  is  also  a  special  indication  for  the 
strict  observance  of  every  rule  of  antisepsis  and  asepsis 
before,  during,  and  after  the  operation. 

If  a  foreign  body,  after  passing  through  the  lens, 
becomes  embedded  in  the  back  of  the  eye  and  can  not  be 
removed,  and  the  eye  remains  free  from  inflammation,  the 
removal  of  such  a  traumatic  cataract  is  indicated  in  spite 
of  the  existing  complication,  not  so  much  for  the  purpose 
of  restoring  the  eyesight,  as  to  avoid  any  evil  conse- 
quences that  a  cataract  of  this  kind  may  give  rise  to  by 
becoming  over-ripe  (dislocation  into  the  anterior  chamber 
or  into  the  vitreous). 

It  is  to  be  remembered  that  by  removing  a  cataract  the 
eyesight  may  be  restored  to  a  considerable  degree  even 
when  the  splinter,  which  may  be  a  particle  of  copper  or 
of  iron,  remains  embedded  in  the  eye ;  and  if  the  foreign 
body  becomes  well  encysted,  vision  may  be  preserved  for 
some  years. 

If,  as  rarely  happens,  a  particle  of  copper  or  stone 
becomes  embedded  in  the  lens,  it  should  be  allowed  to 
stay  there  if  it  is  well  tolerated  until  the  lens  has  become 
completely  opaque,  when  the  foreign  body  is  removed 
along  with  the  cataract.  But  if  the  foreign  body  in  the 
lens  is  of  iron,  it  is  better  to  extract  it  as  soon  as  possible 
with  the  large  magnet  (see  Magnet-operation)  and  to 
operate  on  the  cataract  later. 

Traumatic  cataract  may  also  be  produced  by  a  severe 
blow  on  the  eye  lacerating  the  capsule  of  the  lens.  The 
laceration  usually  occurs  in  the  equatorial  region  of  the 
lens.  This  also,  as  a  rule,  leads  to  total  cataract ;  at  the 
same  time,  however,  the  neighboring  zonule  of  Zinn  is 
also  torn.  This  complication,  which  has  a  very  import- 
ant bearing  on  the  operation,  is  not  always  easy  to  recog- 
nize ;  but  it  may  manifest  itself  by  the  appearance  of  a 
small  portion  of  vitreous  making  its  way  from  behind  the 
iris  into  the  pupil,  which  is  often  somewhat  distorted,  and 
this  prolapse  of  the  vitreous  can  be  recognized  under 
strong  lateral  illumination  and,  if  necessary,  with  the  aid 


OPERATION  FOR   TRAUMATIC  CATARACT.        Ill 

of  a  lens.  The  iris  is  forced  away  from  the  lens  at  the 
corresponding  point.  Laceration  of  the  zonule  of  Zinn, 
when  of  considerable  size,  often  manifests  itself  by  slight 
tremor  of  the  lens,  which  at  the  same  time  may  be  some- 
what decentered — i.  e.,  displaced  toward  the  side  opposite 
the  laceration.  Finally,  there  are  cases  in  which  the  iris 
is  torn  from  its  ciliary  attachment  before  laceration  of  the 
zonule  of  Zinn  takes  place,  so  that  the  absence  of  the 
zonule  can  be  seen  directly  through  the  black  opening 
formed  by  the  iridodialysis,  it  being  impossible  to  see  the 
fine  radiating  fibers  of  the  structure,  either  with  the 
ophthalmoscope  or  under  lateral  illumination  with  a  mag- 
nifying lens. 

Whether  laceration  of  the  zonule  is  diagnosticated  or 
only  surmised,  the  danger  of  prolapse  of  the  vitreous, 
which  infallibly  forces  its  way  into  the  corneal  incision, 
must  be  kept  constantly  in  mind  when  operating  on  a 
traumatic  cataract  produced  by  the  violent  impact  of  a 
blunt  body.  A  cataract  of  this  kind  should  therefore, 
whenever  possible,  be  extracted  by  the  operation  of  discis- 
sion with  two  needles,  without  making  any  corneal  incis- 
ion. The  discission  wound  in  the  capsule  should  be 
very  small,  so  as  to  prevent  the  escape  of  a  large  quan- 
tity of  lenticular  material  into  the  anterior  chamber  and 
the  development  of  glaucoma.  If,  owing  to  the  small 
size  of  the  capsular  opening,  absorption  is  interrupted 
because  the  cells  of  capsular  epithelium  sometimes  cover 
up  the  gap,  a  second  or  third  discission  through  the  same 
opening  in  the  capsule  may  be  cautiously  performed  to 
remedy  the  trouble.  Although  this  method  is  slow,  it  is 
very  much  safer  than  any  other  and  is  to  be  recommended 
above  all  others  in  these  cases. 

Whether  the  cause  of  a  traumatic  cataract  be  one  or 
the  other  of  the  above-mentioned  factors,  it  may  be  par- 
tial and  may  never  become  total.  If  the  partial  cataract 
interferes  with  vision,  as  is  sometimes  the  case,  for  exam- 
ple, when  it  forms  a  figure  like  a  rosette  at  the  posterior 
pole,  and  if  the   vision  of  the  other  eye  is  feeble  and  it 


112  OPE  BÄTIONS  ON  THE  EYE. 

becomes  necessary  to  restore  the  vision  of  the  injured  eye, 
the  procedures  to  be  described  in  the  following  section  are 
to  be  adopted. 

(d)  Operation  for  Partial  Stationary  Cataract. 

Partial  cataract,  which  does  not  go  on  to  complete 
clouding  of  the  lens,  is  usually  treated  while  the  patient 
is  still  young. 

lamellar  Cataract. — This  is  the  most  frequent  and 
therefore  the  most  important  example  of  the  class.  It 
develops  chiefly  in  children  suffering  from  convulsions 
and  rachitis  and  is  almost  always  bilateral.  The  charac- 
teristic features  are  an  anterior  and  posterior  layer  of 
opacity  surrounding  a  nucleus  of  variable  size,  which  is 
either  clear  or  only  slightly  opaque.  When  the  nucleus 
is  large,  the  opaque  layers  are  near  the  capsule  of  the 
lens ;  when  it  is  small,  the  capsule  is  separated  from  the 
opaque  portions  by  a  broad  layer  of  clear  cortical  matter. 
The  opacity  of  the  two  layers,  the  edges  of  which  may 
overlap  like  segments  of  a  sphere,  may  be  of  a  variable 
degree  of  intensity.  When  the  opacity  is  only  slight,  the 
eye  is  not  impervious  to  direct  light  and  the  individual's 
vision  is  only  moderately  reduced.  There  are  cases  in 
which  the  opacity  is  so  slight  as  practically  not  to  inter- 
fere with  vision  at  all ;  in  such  cases  we  may  speak  of  a 
rudimentary  lamellar  cataract.  As  a  rule,  however,  the 
opacity  is  such  as  to  impair  the  visual  power,  especially 
if  the  child  is  going  to  school  and  there  is  a  considerable 
demand  on  the  eyes ;  for  this  reason  children  with  lamel- 
lar cataracts  present  themselves  for  treatment  during  the 
school  years. 

The  best  treatment,  as  a  rule,  consists  in  removal  of  the 
lens,  because  optic  iridectomy,  which  will  be  mentioned 
later,  frequently  leaves  the  eye  with  incomplete  vision, 
and  the  success  of  the  procedure  under  certain  circum- 
stances may  be  diminished  by  the  fact  that  later,  as  the 
patient  becomes  older,  the  cortical  layer,  which  up  to  that 


OPERA  TION  FOR  PA  R  TIA  L  STA  TION.  1 R  Y  CA  TA  RA  CT.  1 1 3 

time  had  remained  unaffected  and  which  through  the 
iridectomy  becomes  accessible  to  the  rays  of  light  that 
enter  the  eye,  gradually  becomes  more  and  more  opaque ; 
although,  as  a  rule,  the  opacity  in  this  variety  of  cataract 
remains  stationary  until  extreme  old  age  and  is  limited  to 
the  zone  between  the  nucleus  and  the  cortex.  Iridectomy, 
however,  can  only  be  performed  in  a  comparatively  small 
group  of  cases,  in  which  the  lamellar  cataract  is  small 
enough  to  leave  room  for  the  rays  of  light  to  enter  the  eye 
after  the  iridectomy  has  been  performed.  In  the  great 
majority  of  perinuclear  cataracts  radical  operation  by  re- 
moval of  the  lens  is  indicated. 

This  operation  can  be  performed  in  one  of  two  way-  : 
either  by  discission  followed  by  a  short  incision  of  the 
cornea,  or  by  immediate  removal  through  a  large  curved 
incision.  The  latter  method  is  adapted  only  for  old  per- 
sons in  whom  a  hard  nucleus  has  already  formed.  These 
cataract  patients  retain  fairly  good  vision  long  after  they 
have  passed  middle  age ;  gradually,  however,  the  opacity 
of  the  lamellar  cataract  or  that  of  the  nucleus  increases 
and  the  patient  is  unable  to  work.  The  cortical  layer, 
unless  it  has  become  cloudy  from  senile  cataract,  adheres 
to  the  capsule  and  has  to  be  absorbed  later.  In  child- 
hood, on  the  other  hand,  which  is  the  time  when  most 
lamellar  cataracts  are  removed,  the  proper  treatment  is 
discission,  because  it  at  once  induces  opacity  and  softening 
of  the  cortical  layer  and  of  the  nucleus  and  thus  permits 
absorption  to  take  place.  In  most  cases,  however,  the 
swelling  of  the  cortical  masses  forces  the  nucleus,  after  it 
has  become  more  or  less  cloudy  as  the  result  of  the  discis- 
sion, through  the  opening  in  the  anterior  capsule  either  as 
a  whole  or  in  fragments,  so  that  the  latter  occupy  the 
anterior  chamber,  and  it  is  then  advisable  to  make  an 
incision  in  the  cornea  and  evacuate  the  cataractous  mass 
in  order  to  shorten  convalescence.  In  very  small  children 
and  in  larger  children  who  are  unmanageable  it  is  of 
course  wiser  to  avoid  a  corneal  incision  as  much  as  pos- 
sible and,  whenever  it  is  feasible,  to  be  content  with  mere 


114  OPERATIONS  ON  THE  EYE. 

incision  and  absorption.  If,  however,  it  becomes  neces- 
sary to  relieve  the  tension  in  the  anterior  chamber  by 
evacuating  its  contents,  it  is  best  to  make  a  short  incision 
not  more  than  5  to  6  mm.  in  length  between  the  edge  and 
the  center  of  the  cornea. 

The  individual  steps  of  this  procedure  have  already 
been  described,  and  it  is  evident  that  they  must  be  carried 
out  with  due  observance  of  antiseptic  precautions. 

Whenever  in  the  case  of  older  children  it  becomes 
necessary  to  remove  the  lamellar  cataract  without  loss  of 
time,  as  for  example,  in  order  not  to  keep  the  child  out 
of  school  too  long,  it  is  advisable  to  divide  the  anterior 
capsule  along  with  the  anterior  cortical  layer  by  a  liberal 
incision,  which  should  even  be  carried  into  the  nucleus  so 
as  to  admit  the  aqueous  humor.  This  is  a  better  pro- 
cedure in  such  cases  than  discission,  performed  with  one 
needle  in  the  manner  already  described,  and  is  done  with 
two  Bowman's  discission  needles  (Fig.  56).  The  two 
needles  are  inserted  opposite  the  peripheral  portion  of  the 
cornea,  as  shown  in  Plate  4,  for  the  secondary  operation 
on  cataract ;  the  points  of  the  needles  are  then  brought 
close  together  and  introduced  into  the  lens  and  then 
separated  again,  at  first  in  a  horizontal,  and  then  in  a 
vertical  direction,  so  as  to  make  quite  a  large  and  deep 
crucial  incision.  The  object  of  using  two  needles  is  to 
avoid  dragging  the  lens  about  and  thus  tearing  the  zonule. 
For  the  sake  of  greater  security,  if  the  child  has  not  been 
chloroformed,  which  is  as  a  rule  an  unnecessary  pre- 
caution, it  is  advisable  to  have  an  assistant  to  steady  the 
eye  with  a  fixation-forceps  in  order  to  guard  against  any 
laceration  through  sudden  movements  of  the  globe.  This 
is  not  shown  in  Plate  4. 

In  performing  discission  with  Bowman's  needles  it  is  very  important 
to  see  that  the  needles  are  properly  constructed.  Nowadays  needles 
are  manufactured  which  do  not  possess  the  chief  advantage  of  Bow- 
man's needles — namely,  that  of  preventing  the  escape  of  aqueous  humor 
during  the  operation.  This  is  accomplished  by  making  the  needle 
thick  enough  so  that  the  part  immediately  behind  the  point  com- 
pletely occludes  the  wound  as  the  needle  is  thrust  through  the  cornea. 


OPERA  TION  FOR  PA  R  TIA  L  STA  TIOXAR  Y  CA  TARA  CT  115 


Even  if  the  latter  is  not  introduced  as  far  as  the  stop  (Fig.  6  (a)  2), 
the  wound  is  supposed  to  be  closed  not  by  the  stop,  but  by  the  shaft 
between  it  and  the  point,  which  must  be  thicker  than  the  point  at  its 
greatest  width.  As  soon  as  the  point  has  penetrated  the  cornea,  the 
shaft  (between  1  and  2)  should  at  once  com- 
pletely occlude  the  wound.  For  in  the  case 
of  children  it  may  happen  that  the  needle 
can  not  be  inserted  as  far  as  the  stop  in  this 
operation,  and  the  stop  can  not  therefore  be 
used  as  an  obturator.  If  the  wound  is  prop- 
erly occluded  by  the  needle,the  normal  depth 
i  if  the  anterior  chamber  is  preserved  and  the 
distance  between  the  lens  and  the  cornea  does 
not  change  during  the  operation.  But  if 
the  needle  is  not  properly  constructed,  as 
shown  in  Fig.  6  (b),  the  large  wound  made 
by  such  a  lance-shaped  instrument  will  not 
be  occluded  by  the  posterior  portion  of  the 
needle,  the  aqueous  humor  escapes  along 
the  shaft  as  soon  as  the  edge  of  the  needle 
has  passed  the  cornea,  and  the  lens  at  once 
approaches  the  cornea.  Under  such  cir- 
cumstances it  is  quite  impossible  to  intro- 
duce the  needle  as  far  as  the  stop,  so  as  to 
use  it  to  occlude  the  wound,  because  by 
doing  so  the  needle  would  be  thrust  too  far 
into  the  lens.  The  aqueous  humor  accord- 
ingly continues  to  escape  and,  if  discission 
is  performed  under  such  circumstances, 
there  is  great  dancer  of  tearing  the  pos- 
terior capsule  also,  because  the  lens  rapidly 
advances  toward  the  cornea,  especially  if 
the  child  begins  to  cry.  An  injury  to  the 
posterior  capsule  is  a  very  serious  blunder 
in  this  operation  and  brings  its  own  pun- 
ishment when  the  operator  is  later  obliged 

to  puncture  the  anterior  chamber;  for  some  of  the  vitreous  is  sure  to 
force  its  way  into  the  wound,  which  can  not  be  regarded  as  anything 
but  a  very  grave  complication. 

When  instead  of  Bowman's  needles  a  capsular  knife  is  used  for  this 
operation,  as  for  example,  Knapp's  knife  (Fig.  58),  the  knife  must  be 
constantly  tested  on  the  chamois  to  determine  whether  the  shaft  occludes 
the  incision. 


(I  0 

Fig.  6.— a,  Discission 
needle  properly  constructed 
to  occlude  the  wound;  ft, 
one  that  does  not  occlude 
the  wound  (greatly  magni- 
fied). 


As  soon  as  the  capsule  and  the  lens  substance  have  thus 
been  freely  laid  open,  the  lenticular  material  begins  to 
become  cloudy  and  rapidly  swells.  But  by  keeping  the 
pupil  dilated  so  as  to  prevent  the  formation  of  synechia? 


116  OPERATIONS  ON  THE  EYE. 

it  is  quite  safe  to  wait  until  either  the  tension  increases  or 
a  considerable  quantity  of  gray  cataract  material  has 
entered  the  anterior  chamber,  including  within  it  the  more 
or  less  fragmented  and  opaque  nuclear  portion.  The 
more  the  anterior  chamber  becomes  filled  with  this  grayish, 
translucent  mass,  which  resembles  glue,  the  more  easy 
will  be  evacuation  with  a  keratome  incision  as  sketched  in 
Fig.  4.  If  necessary  the  puncture  may  be  repeated  if 
the  first  does  not  suffice  to  clean  up  the  pupillary  region. 

If  the  tension  becomes  increased  during  the  course  of  the 
treatment,  the  condition  may  be  corrected  by  making  a 
small  puncture  of  the  cornea  with  a  narrow  keratome  or 
linear  knife  and,  if  necessary,  repeating  the  operation. 
A  rise  in  tension  should  never  be  regarded  as  an  imme- 
diate indication  for  iridectomy.  In  fact,  iridectomy,  as 
has  already  been  intimated,  is  to  be  excluded  on  general 
principles  in  the  case  of  young  patients.  If  the  iris 
glides  into  the  wound  after  incision  of  the  anterior  cham- 
ber, it  must  be  at  once  replaced  with  a  spatula  and  con- 
traction of  the  pupil  brought  about  by  instilling  physo- 
stigmin.  If  an  anterior  synechia  forms  in  the  corneal 
opening  it  can  be  divided  later  in  the  manner  to  be 
described. 

Finally,  it  is  necessary  in  most  cases,  in  order  to  obtain 
as  good  vision  as  possible,  to  perform  discission  on  the 
posterior  capsule  and  any  remaining  cataractous  material ; 
this  is  done  in  the  same  way  as  a  secondary  operation  for 
cataract,  which  will  be  described. 

The  entire  duration  of  the  treatment  when  discission, 
combined  with  corneal  incision,  is  used  may  be  from  six 
to  eight  weeks.  If  discission  is  used  alone,  without  punct- 
ure, the  treatment  may  last  even  longer;  but  the  most 
important  consideration  in  these  cases  is  to  choose  the 
safest  and  not  the  shortest  method,  especially  as  most  of 
the  children  have  plenty  of  time  and  the  danger  of  pro- 
lapse of  the  vitreous  into  the  wound  must  be  specially 
guarded  against,  because  in  children  it  is  usually  followed 
by  bad  recovery  with  iritis,  cyclitis,  and  distortion  and 


OPERA  TION  FOR  PA  R  TIA  L  STA  TIONAR  Y  CA  TARA  CT.  117 

occlusion  of  the  pupil.  The  different  operations  must  not 
be  performed  in  too  rapid  succession,  else  there  will  be 
danger  of  iridocyclitis.  It  is  also  advisable  not  to  operate 
on  both  eyes  at  the  same  time,  because,  if  the  child  should 
be  unfortunate  enough  to  contract  a  disease — such  as 
scarlet  fever  or  diphtheria — accidentally,  or  the  wound 
should  become  infected,  both  eyes  might  be  destroyed. 

It  is  most  important  in  these  cases  of  lamellar  cataract 
to  secure  smooth  recovery,  with  a  round,  perfectly  mov- 
able, clean  pupil  in  correct  position  for  the  reason,  even 
when  recovery  is  ideal,  the  visual  power  quite  frequently 
turns  out  to  be  only  moderately  good  (from  ^  to  f), 
although  there  does  not  seem  to  be  any  cause  for  this  want 
of  success.  Ultimate  vision  of  \-  constitutes  a  disability. 
If  before  the  operation  the  patient  had  a  visual  acuity  of 
J,  and  it  is  not  increased  by  the  operation,  the  removal 
of  the  lens  has  been  of  no  benefit  to  him  ;  for  he  has  been 
deprived  of  his  accommodation  and  will  require  a  thick 
convex  glass  (cataract  glass)  for  distinct  near  vision,  and 
most  patients  who  have  to  be  operated  on  for  cataract  find 
this  very  unpleasant. 

If,  therefore,  in  a  case  of  lamellar  cataract  the  indi- 
vidual still  has  a  visual  acuity  of  J  to  J-,  an  operation  is 
permissible  only  if  there  is  some  certainty  that  it  will  be 
followed  by  an  uninterrupted  recovery  and  a  fairly  good 
result ;  otherwise  it  would  be  better  not  to  operate,  for 
there  is  always  a  possibility  of  more  favorable  conditions 
for  its  removal  developing  later. 

As  a  rule  the  opacity  of  a  lamellar  cataract  and  the 
reduction  of  vision  are  nearly  the  same  on  the  two  sides, 
but  in  some  cases  there  is  a  difference.  In  such  cases  it 
is  well  to  operate  on  the  worst  eye,  and  not  to  interfere 
with  the  other  if  near  vision  is  still  fairly  good,  so  that, 
if  the  patient  happens  to  loose  his  reading  glasses,  he  is 
not  entirely  helpless  so  far  as  near  vision  is  concerned. 

The  same  treatment  as  for  lamellar  cataract  is  indicated 
for  other  stationary,  partial  cataracts  in  young  individuals, 
such  as  spindle  cataract,  anterior  and  posterior  polar  cata- 


118  OPERATIONS  ON  THE  EYE. 

ract,  etc.  These  forms  rarely  come  to  operation.  With 
regard  to  anterior  polar  cataract,  which  occasionally  pro- 
duces a  distinct  increase  of  the  white  discoloration  at  the 
anterior  pole  in  the  form  of  a  pyramidal  cataract,  it  is  evi- 
dent from  what  has  been  said  about  capsular  cataract  that 
it  can  not  be  removed  by  itself,  as  by  scraping,  for  example, 
because  it  is  a  capsular  cataract  and  is  therefore  under- 
neath the  capsule.  Small  opacities  of  this  kind  do  not 
interfere  with  vision  enough  to  require  operation  ;  large 
anterior  capsular  cataracts,  which  obstruct  the  greater 
portion  of  the  pupillary  region,  must  be  treated  either  by 
doing  a  small  optical  iridectomy  or  by  discission — i.  e., 
they  must  be  removed  along  with  the  entire  lens. 

Opacities  on  the  posterior  pole  of  the  lens,  on  the  other 
hand,  cause  a  much  greater  disturbance  of  vision.  They 
are  occasionally  met  in  youthful  individuals  who  present 
no  other  disease  of  the  eyes.  Strictly  speaking,  this  form 
of  opacity  usually  belongs  to  the  progressive  varieties,  but 
it  sometimes  increases  so  slowly  that  it  is  impossible  to 
wait  for  total  clouding  of  the  lens  to  take  place.  It  is 
better  to  follow  the  same  line  as  in  lamellar  cataract,  pro- 
viding there  are  no  complications,  such  as  iritis,  vitreous 
opacities,  choroiditis,  or  retinitis,  to  contra-indicate  such 
a  procedure. 

(e)  Operation  for  Senile  Cataract. 

The  following  points  in  the  interesting  history  of  operation  for 
senile  cataract  are  worthy  of  notice  : 

Until  the  year  1745,  when  Jaques  Daviel  (1696-1762)  first  removed 
a  cataract  from  the  eye,  an  operation  for  cataract  consisted  not  in 
removing  the  cloudy  lens  from  the  eye,  but  merely  in  getting  it  out  of 
the  way,  either  by  means  of  the  so-called  cataract  puncture,  by  which 
it  was  pushed  down  into  the  vitreous  (depression)  or  turned  over  back- 
ward ( reclination,  couching).  This  comparatively  simple  operation  was 
usually  performed  by  itinerant  "cataract-stickers."  If  the  operation 
was  successful  the  patient,  who  before  had  been  blind,  at  once  was  able  to 
see  with  the  aid  of  a  cataract  lens.  Unfortunately,  however,  there  were 
many  cases  in  which  the  patient  did  not  long  enjoy  this  happiness.  It 
often  happened  that  the  lens,  after  a  short  time,  was  again  displaced  by 
the  vitreous  body  assuming  its  original  position  and  again  obstructing 
the  view,  and  still  more  frequently  it  happened  that  the  operation  was 


OPERATION  FOR  SEXILE  CATARACT.  119 

followed  by  infection  or  glaucoma  with  more  or  less  pain  and,  ulti- 
mately, blindness.  Glaucoma  was  frequently  responsible  for  the 
destruction  of  eyes  that  had  been  treated  in  this  way.  Nevertheless 
this  rude  method  of  puncturing  cataracts  was  carried  on  in  many  parts 
of  Europe  until  well  into  the  nineteenth  century,  and  is  still  practised 
by  the  natives  of  India,  where  cataract  is  so  common.  For  cataract 
extraction  is  a  much  more  difficult  and  circumstantial  operation  and 
took  some  time  to  make  its  way  in  practice. 

Daviel  extracted  the  cataract  through  a  corneal  incision  which  took 
in  from  one-half  to  two-thirds  of  the  lower  circumference  of  the  cornea, 
thus  forming  a  large  flap  as  wide  as  one-half  the  diameter  of  the 
cornea.  Wenzel— both  father  and  son — on  the  other  hand,  used  a  flap 
directed  inward  and  upward.  Gottlob  August  Richter,  in  Göttingen 
( 1742-1812),  and  Beer,  in  Vienna  1 1763-1821 ),  again  made  their  incis- 
ion at  the  lower  border  of  the  cornea  with  a  somewhat  smaller  flap, 
although  Richter  raised  the  question  whether  it  would  not  be  better  to 
make  the  incision  above.  The  lower  incision  was,  however,  unques- 
tionably easier  of  execution,  because  during  the  operation  the  eye  is 
reflexly  rotated  upward  as  soon  as  the  pain  begins.     For  this  reason 


Fig.  7.— Flap  incision  (after  Beer) :  a,  b,  Fig.  8.— von  Gräfe's 

Horizontal  diameter  of  the  cornea.    The  linear  incision, 
dotted    curved    line  indicates    the    inner 
wound;  the  solid  line,  the  outer  wound. 


most  operators  made  the  flap  incision  below  until  A.  von  Gräfe's  time 
(see  Fig.  7). 

For  the  sake  of  greater  security  and  to  obtain  a  smooth  incision 
special  knives  were  devised.  That  of  Beer  had  the  form  of  a  flat 
triangle  (see  Fi#.  119). 

After  the  incision  had  been  made,  the  rest  of  the  operation  consisted 
merely  in  opening  the  capsule  of  the  lens  and  delivering  the  cataract, 
with  gentle  pressure,  through  the  capsular  opening,  the  pupil,  and  the 
corneal  wound.  As  it  was  customary,  in  order  to  obtain  a  better  view 
of  the  cataract  and  assist  in  its  escape,  to  dilate  the  pupil  with  bella- 
donna, prolapse  of  the  iris  into  the  large  corneal  wound — an  accident 
that  is  very  apt  to  happen  with  this  incision — was  still  further  facili- 
tated and  frequently  developed  even  after  the  operation.  This  increased 
the  danger  of  wound  infection,  caused  a  faulty  position  of  the  pupil, 
disturbed  the  curvature  of  the  cornea  and,  finally,  left  the  eye  with  a 
tendency  to  glaucoma.  It  also  happened  quite  frequently  that  the  large 
corneal  flap,  either  during  or  after  the  operation,  would  be  turned  over 


120  OPERATIONS  ON  THE  EYE. 

Fig.  9. — Noyes'  stop-speculum. 

Fig.  10. — Clark's  (Weiss)  stop-speculum. 

Fig.  11. — Weiss'  stop-speculum. 

Fig.  12. — Roster's  stop-speculum. 

Fig.  13.— Mellinger's  stop-speculum. 

The  stop-specula  shown  in  this  and  the  following  figure-plates  (Figs. 
14,  24,  33,  34)  are  intended  to  illustrate  the  most  important  models 
among  the  numerous  instruments  of  this  kind,  both  as  regards  the  stop- 
mechanism,  which  in  most  of  them  consists  of  a  screw,  and  in  others  of 
a  ratchet  (Figs.  12,  13,  34),  and  as  regards  the  curvature  and  the  con- 
struction of  the  arms  of  the  instruments,  which  are  introduced  under- 
neath the  lids.  In  a  number  of  the  specula  the  latter  are  provided  with 
a  wire  (Figs.  9  and  12)  or  a  solid  plate  (Figs.  11,  14.  33)  for  protection 
against  the  lashes.  A  solid  plate,  however,  takes  up  too  much  room 
unless  it  is  curved,  as  in  Lang's  newest  model  (Fig.  33).  One  of  the  first 
requisites  of  a  good  speculum  is  that  it  shall  be  possible  to  close  it  quickly 
and  surely,  so  that  it  can  be  removed  from  the  eye  without  difficulty. 


backward  by  spasmodic  closure  of  the  lids,  and  the  bruising  to  which  it 
was  thus  subjected  also  gave  rise  to  infection  and  suppuration.  In  fact, 
suppuration  was  not  at  all  rare  after  the  operation,  occurring  in  5  to  10 
per  cent,  and  more  of  the  cases.  It  was  a  complication  that  was  spe- 
cially dreaded,  and  thoughtful  operators  attributed  it  chiefly  to  the 
large  size  of  the  flap  and  to  the  fact  of  its  occupying  a  tissue  poorly 
supplied  with  blood-vessels  and  therefore  unfavorably  situated  for  nutri- 
tion, as  it  was  not  difficult  to  show  that  similar  but  smaller  incisions,  as, 
for  example,  in  iridectomy,  showed  much  less  tendency  to  suppuration. 

The  result  of  this  reasoning  was  that  Jacobson  gave  up  the  large 
corneal  incision  and  instead  incised  the  lower  border  of  the  sclera  ; 
this,  however,  increased  the  danger  of  escape  of  the  vitreous  to  such  a 
degree  that  the  operation  was  found  to  be  impossible  except  under  pro- 
found anesthesia. 

Albrecht  von  Gräfe  (1828-1870),  of  Berlin,  who  brought  about  a 
complete  revolution  in  the  method  of  treating  a  cataract,  not  only 
transferred  the  incision  to  the  sclera,  but  reduced  its  size  as  much  as 
possible,  which,  of  course,  made  the  escape  of  the  cataract  more  diffi- 
cult. He  also  tried  to  avoid  the  formation  of  a  flap  altogether  by 
placing  his  incision  as  much  as  possible  in  the  meridian  of  the  globe,  so 
that,  when  viewing  the  meridian  from  above,  the  incision  formed  a 
straight  line.  Hence,  von  Gräfe's  incision  was  called  the  "  linear 
incision,"  and  his  method  the  "linear  extraction"  and,  in  contradis- 
tinction to  the  already  mentioned  simple  operation,  the  "modified  linear 
extraction."  As  the  incision  was  so  very  near  the  periphery,  and, 
owing  to  the  small  size  of  the  wound,  the  iris  got  in  the  way  of  the 
escaping  cataract  and  suffered  more  or  less  contusion,  depending  on  the 
size  of  the  hard  nucleus,  von  Gräfe  added  iridectomy  to  the  cataract 
incision ;  and  in  order  to  minimize  the  disadvantage  of  allowing  so 
much  light  to  enter  the  eye,  as  well  as  to  avoid  disfigurement,  he  placed 


121 


122  OPERATIONS  ON  THE  EYE. 

Fig.  14. — Gaupillat  stop-speculum  with  jointed  blades  and  movable 
end-plates. 

Figs.  15,  16. — Desmarres'  speculum, 

Fig.  17. — Simple  wire-speculum,  showing  at  the  other  end  Jager's 
horn  spatula  for  operations  on  the  lid. 

Fig.  18. — Noyes'  speculum. 

the  incision  for  extraction  above,  so  that  the  iridectomy  (coloboma) 
was  covered  by  the  upper  lid.  To  insure  greater  accuracy  in  making 
the  incision  he  devised  a  special,  narrow  knife,  resembling  a  spear  of 
grass  (see  Fig.  26). 

A  narrow  blade  of  this  kind  was,  it  is  true,  the  best  instrument  for 
making  this  somewhat  difficult  linear  incision,  which  was  bounded  at 
the  extremities  by  the  two  lateral  tangents  of  the  cornea  (Fig.  8)  ;  but 
even  with  Griife's  knife  it  was  a  difficult  feat,  after  entering  at  a  and 
advancing  the  point  toward  the  middle  of  the  pupil,  to  make  the  wound 
of  exit  correctly  at  b.  In  his  desire  to  make  the  wound  large  enough 
the  operator  was  apt  to  bring  the  point  of  the  knife  out  at  a  point  too 
far  away  from  the  corneal  margin,  thus  getting  into  the  dangerous 
region  of  the  ciliary  body ;  or,  in  his  anxiety  to  avoid  the  ciliary  body, 
he  would  bring  out  the  knife  at  a  point  too  near  the  corneal  margin, 
and  thus  make  too  small  an  incision,  through  which  it  was  difficult  to 
deliver  the  cataract,  even  after  the  iris  had  been  excised  and  the  cap- 
sule opened  with  the  knife  (Fig.  29)  introduced  by  von  Gräfe.  Thus 
the  escape  of  the  lens  had  to  be  assisted  with  spoons,  and  a  good  deal 
of  the  cortical  matter  was  thus  scraped  off  and  remained  in  the  eye,  to 
be  either  curetted  out  or  "milked  out"  with  the  lower  lid — that  is,  the 
operator,  after  removing  the  speculum  and  fixation-forceps,  kept  up  a 
kind  of  massage  of  the  lid  for  some  time,  exerting  more  or  less  pressure 
on  the  lid  with  the  finger,  and  pushing  it  from  below  upward  over  the 
cornea  in  order  to  express  the  remains  of  the  cataract  through  the 
wound,  which  would  gape  of  its  own  accord.  Personally  I  have  no 
doubt  whatever  that  this  milking  movement,  by  expressing  the  contents 
of  the  glands  in  the  lower  border  of  the  lid,  was  often  a  source  of  in- 
fection ;  for  we  know  that  the  edges  of  the  lids  are  very  frequently  the 
most  infected  part  of  the  eye.  Sometimes,  when  this  method  of  milk- 
ing was  resorted  to,  the  operation  would  terminate  most  disastrously  in 
prolapse  of  the  vitreous,  for  the  peripheral  wound  was  uncomfortably 
near  the  vitreous. 

As  the  incision  was  also  very  near  the  ciliary  body,  inflammation  of 
the  wound  was  very  apt  to  be  followed  by  dangerous  cyclitis,  causing 
not  only  blindness  in  the  operated  eye,  but  not  infrequently  destroying 
the  other  eye  as  well,  through  sympathetic  inflammation. 

However,  postoperative  suppuration  diminished,  and  the  fact  that 
iridectomy  had  to  be  accepted  in  this  method  was  less  objectionable, 
because  the  defect  was  covered  by  the  upper  lid.  Owing  to  the  dimin- 
ished curvature  of  the  incision,  the  wound  healing  more  rapidly,  and  the 
shortened  length  of  the  incision  were  probably  chiefly  responsible  for 
the  better  results  that  were  obtained ;  for,  as  we  now  know,  it  was  a 


18 


123 


124  OPERATIONS  ON  THE  EYE. 

mistake  to  suppose  that  iridectomy  diminishes  the  danger  of  postoper- 
ative inflammation. 

Nevertheless  the  danger  of  this  incision  caused  even  a  partial  return 
to  the  corneal  margin,  even  among  many  of  von  Gräfe' s  followers,  thus 
giving  the  incision  a  certain  degree  of  curvature.  Iridectomy,  how- 
ever, was  retained.  During  the  seventh  and  eighth  decades  of  the  last 
century,  when  the  knowledge  of  antisepsis  and  asepsis  and  of  the  use  of 
miotics  and  of  cocain  was  gained,  there  was  a  growing  tendency  to 
return  more  and  more  to  the  old  flap  incision  and  to  suppress  iridec- 
tomy whenever  possible.  As  the  true  causes  and  correct  method  of 
combating  suppuration  became  better  known  the  dread  of  such  a  compli- 
cation diminished  correspondingly.  Prolapse  of  the  iris,  it  was  found, 
could  be  combated  by  means  of  the  miotics,  especially  physostigmin, 
and  it  became  possible  to  retain  the  upper  incision  because  the  pain 
of  the  operation  was  practically  reduced  to  zero  by  the  use  of  cocain. 

Incidentally  it  was  also  found  that  it  is  easier  to  get  along  without 
iridectomy  if  the  incision  is  so  large  that  it  takes  in  nearly,  if  not 
quite,  one-half  of  the  cornea,  and  it  was  also  found  that  the  incision 
may  safely  be  quite  near  the  periphery,  although  it  might  be  supposed 
a  priori  that  these  two  factors  would  favor  prolapse  of  the  iris.  The 
reason  is  that  when  the  incision  is  large  and  near  the  periphery  the 
cataract  can  escape  much  more  easily  without  any  contusion  of  the 
iris.  It  is  true  that  the  iris  is  momentarily  subjected  to  great  disten- 
tion as  the  cataract  escapes  through  the  pupil  ;  but  if  it  has  not  been 
previously  paralyzed  by  atropin  it  usually  contracts  again  vigorously 
and  returns  into  the  anterior  chamber  to  its  proper  position,  which  it 
will  retain  if  the  patient  afterward  remains  quiet  until  the  wound  has 
united.  Reopening  of  the  wound,  however,  may  at  any  time  be  fol- 
lowed by  prolapse  of  the  iris,  because  the  aqueous  humor  washes  the 
iris  into  the  wound.  It  is  therefore  wise  to  assist  rapid  closure  of  the 
wound  by  making  a  conjunctival  flap. 

Preparatory  Treatment  for  Operation  on  Senile 
Cataract. — All  preliminary  procedures,  including  exami- 
nations, must  be  carefully  carried  out  with  due  regard  both 
to  the  patient's  general  health  and  the  condition  of  the 
eye,  as  well  as  its  functions. 

With  regard  to  the  functional  examination,  especially  that  of  the 
macula  lutea,  the  following  should  be  borne  in  mind :  In  the  case  of  a 
cataract  that  has  not  become  completely  opaque,  although  operable, 
central  vision  (according  to  Pagenstecher)  may  be  tested  by  dilating 
the  pupil  and  examining  the  patient  with  the  stenopeic  slit-hole  and  a 
strong  convex  lens,  moving  it  back  and  forth  in  front  of  the  dilated 
pupil  until  the  patient  finds  the  clearest  spot  in  the  lens.  The  size  of 
the  finest  print  that  the  patient  is  able  to  read  will  serve  to  indicate  the 
visual  power  of  the  macula.  This  method  of  examination  is  useful 
when  it  is  possible  to  see  changes  in  the  macula  through  the  opaque 
lens,  and  there  is  a  doubt  in  the  examiner's  mind  whether  the  condition 
of  the  macula  is  still  good  enough  to  justify  operation  on  the  cataract. 


OPERATION  FOR  SENILE  CATARACT.  125 

If  the  patient  is  intelligent,  Pagenstecher  believes  that  the  behavior 
of  Purkinje'*  vascular  figure  will  indicate  the  functional  condition  of 
the  macula,  even  when  the  lens  is  completely  opaque. 

As  regards  the  general  condition,  it  is,  above  all,  im- 
portant to  examine  the  urine  once  or  twice  for  albumin, 
taking  a  specimen  of  the  urine  passed  between  10  and  12 
o'clock  in  the  morning,  as  well  as  for  sugar,  taking  for 
the  latter  purpose  a  specimen  of  urine  passed  between  3 
and  4  o'clock  in  the  afternoon,  after  a  meal  containing 
carbohydrate  and  sugar. 

Fever,  even  of  a  very  slight  degree,  is  a  contra-indica- 
tion. 

It  is  especially  important  to  examine  a  patient  with  a 
cataract  for  the  presence  of  suppuration  in  any  part  of  the 
body  (leg-ulcer,  eczema,  fistula  of  any  kind),  and  for  any 
spot  on  the  skin  that  may  become  the  starting-point  of 
erysipelas  (fissures  behind  the  ears  and  at  the  nose,  etc.). 
All  such  sources  of  wound-infection  must  be  rendered 
innocuous,  either  by  curing  them  or  covering  them  with 
an  antiseptic  dressing  before  the  operation  is  undertaken. 

The  most  dangerous  form  of  suppuration  for  a  cataract 
patient  is  suppuration  in  the  lacrimal  sac.  Even  a 
mere  purulent  catarrh  in  its  structures  suffices  to  cause  a 
most  destructive  infection  of  the  cataract  wound.  Mere 
external  inspection  of  the  eye  and  pressure  on  the  lacri- 
mal sac  are  not  sufficiently  accurate  methods  of  determin- 
ing whether  the  lacrimal  passages  are  normal ;  it  is 
much  better  in  every  case  to  inject  fluid  into  the  lacri- 
monasal  duct,  as  explained  on-  p.  56,  and  to  carry  out 
the  other  procedures  advised  at  that  place.  This  injection 
of  the  lacrimonasal  duct  (the  technic  of  which  will  be 
more  accurately  described  in  the  section  devoted  to  Opera- 
tions on  the  Lacrimal  Apparatus)  may  be  performed  the 
evening  preceding  the  operation  or  in  the  morning,  imme- 
diately before  beginning  the  operation. 

The  conjunctiva  also  must  be  carefully  examined,  as 
conjunctival  catarrh  may  be  quite  as  dangerous  as  catarrh 
of  the  lacrimal  sac.     Conjunctival  catarrh,  to  which  old 


126  OPERATIONS  ON  THE  EYE. 

persons  are  so  predisposed,  must  first  be  removed.  If 
the  conjunctiva  merely  appears  somewhat  suspicious  it 
should  be  treated  prophylactically,  at  intervals  of  twenty- 
four  hours,  with  a  1  per  cent,  solution  of  silver  nitrate, 
especially  if  the  dressing  (presently  to  be  mentioned) 
shows  the  presence  of  some  secretion.  [A  25  per  cent, 
solution  of  argyrol,  or  20  per  cent,  solution  of  protargol 
is  even  more  valuable. — Ed.] 

Blepharitis  is  also  a  contra-indication  ;  when  it  is  only 
moderate,  however,  the  operation  may  be  performed,  pro- 
vided an  ichthyol  dressing  is  used. 

The  operator  must  never  forget  to  test  the  intra-ocular 
tension  several  times  in  every  case  of  cataract.  If  the 
tension  is  found  to  be  heightened  from  time  to  time,  even 
if  the  increase  is  only  small,  iridectomy  should  be  per- 
formed first,  and  the  treatmeut  with  miotics  kept  up  until 
the  tension  has  become  normal,  for  glaucoma  following 
an  operation  for  cataract  is  a  grave  condition  that  is  often 
difficult  to  correct. 

Examination  must  also  include  the  other  eye  in  every 
case.  If  it  shows  signs  of  disease,  especially  of  iridocy- 
clitis or  glaucoma,  such  conditions  must  first  be  removed. 
If  it  is  phthisical  and  sensitive  to  pressure  it  is  better  to 
perform  enucleation  first,  especially  if  the  phthisis  has 
followed  an  injury  or  operation.  An  eye  which,  owing 
to  cyclitis,  is  in  danger  of  producing  sympathetic  disease 
of  the  eye  needing  operation,  or  lias  already  produced 
such  sympathetic  disease,  or  only  sympathetic  irritation, 
ought  to  be  enucleated  before  the  other  eye  is  operated 
upon,  if  it  is  blind  or  has  defective  projection  ;  and  enu- 
cleation should  take  place  about  six  to  eight  weeks  before 
the  cataract  extraction.  This  is  because  the  cataract 
operation  may  convert  a  mere  sympathetic  irritation  into 
sympathetic  inflammation. 

In  addition  there  are  certain  other  preliminaries  to  be 
observed  before  an  operation  for  cataract : 

1.  A  bath  for  cleansing  purposes,  or  even  several,  if 
necessary,  in  the  case  of  dirty  patients. 


OPERATION  FOR  SESILE  CATARACT.  127 

2.  The  eyelashes  should  be  carefully  cut  off  without 
injuring  the  skin  of  the  eyelid,  and  the  eyebrows  must  be 
either  trimmed  or  shaved  ;  the  latter  especially  in  the  case 
of  dirty  persons.  This  should  be  done  an  hour — or  imme- 
diately— before  operat  i  ng. 

3.  On  the  evening  preceding  the  day  of  operation  the 
eye  to  be  treated  should  be  bandaged,  and  the  bandage 
must  remain  in  place  until  the  operating  period,  being 
moistened  from  time  to  time  with  a  1  :  5000  solution  of 
bichlorid  of  mercury.  This  preparatory  bandage  has  the 
following  advantages:  The  patient's  sensitiveness  to 
bichlorid  of  mercury  is  determined  ;  for  it  is  well  known 
that  there  are  individuals  in  whom  even  a  small  quantity 
of  very  weak  bichlorid-of-mercury  solution  produces  a 
dermatitis,  which  often  discharges  for  days  in  a  most 
unpleasant  manner,  even  if  the  use  of  the  remedy  is  at 
once  discontinued.  A  dermatitis  of  this  kind,  surround- 
ing an  eye  from  which  a  cataract  has  been  extracted,  is 
capable  of  seriously  endangering  recovery.  If  on  the 
morning  after  the  moist  bichlorid  bandage  has  been  applied 
the  skin  appears  in  the  least  reddened,  operation  must  be 
delayed  until  the  skin  has  become  normal ;  and  in  such  a 
case  the  use  of  bichlorid  of  mercury  must  be  avoided, 
both  before  and  after  the  operation,  simple  sterilized  water 
being  substituted  in  its  stead. 

The  trial  bandage  also  shows  whether  there  is  any  con- 
junctival secretion,  which,  if  present,  will  be  found  on 
the  cotton  pad  that  covers  the  eye.  In  such  a  case  the 
operation  is  also  postponed  until  the  catarrh  has  been 
cured ;  or  at  least,  if  the  conjunctiva  shows  but  little 
catarrhal  change,  it  is  painted  once  or  twice  with  a  1  per 
cent,  solution  of  silver  nitrate  as  a  matter  of  precaution. 
[Argyrol  or  protargol  may  be  used. — Ed.] 

The  chief  advantage  of  the  preliminary  bandage  is  that 
it  makes  it  easier  to  secure  thorough  cleanliness  of  the  skin 
of  the  lids  and  surrounding  parts  before  the  operation, 
because  these  parts  are  softened  by  the  moisture  of  the 
bandage. 


128  OPERATIONS  ON  THE  EYE. 

Fig.  19. — Pamard's  instrument  for  fixing  the  eyeball. 

Fig.  20. — Dujardin's  forceps  for  the  same  purpose,  provided  with  a 
lock. 

Fig.  21. — Fixation-forceps  without  a  lock. 

Fig.  22. — Noyes'  curved  fixation-forceps  with  a  lock. 

Fig.  23. — Fine-toothed  forceps. 

Fixation-forceps  should  be  broad  in  front  and  provided  with  teeth, 
which  should  not  be  too  sharp,  so  as  not  to  tear  through  the  conjunctiva, 
and  thus  defeat  their  purpose.  If  the  conjunctiva  is  friable,  the  instru- 
ments illustrated  in  Fig.  19  or  20  may  be  used. 

[The  editor  doubts  the  necessity  and  even  the  wisdom 
of  a  preparatory  bandage  as  described.  It  is  apt  to  dis- 
turb the  rest  so  much  needed  during  the  night  prior  to 
the  day  of  operation,  and  tends  to  encourage  hyperemia 
of  the  conjunctiva.  If  it  is  used  the  pad  should  be 
soaked  in  boric-acid  solution  or  sterile  water,  because 
many  patients  will  not  tolerate  a  sublimate  solution. — 
Ed.] 

4.  The  bandage  having  been  removed  immediately  be- 
fore the  operation,  cocain  is  instilled  into  both  eyes  to 
guard  against  the  disturbing  accident  of  reflex  closure  of 
the  lid,  in  case  a  drop  of  fluid  of  any  kind  accidentally 
gets  into  the  other  eye  during  the  operation.  All  that  is 
necessary,  as  a  rule,  is  to  instil  5  drops  of  a  freshly  boiled 
3  per  cent,  solution  of  cocain  at  intervals  of  three  minutes, 
[or  3  drops  of  a  4  per  cent,  solution  of  cocain  at  intervals 
of  five  minutes.  Some  operators  prefer  a  1  per  cent,  solu- 
tion of  holocain. — Ed.]  In  the  case  of  patients  with  little 
self-control,  and  in  cases  in  which,  owing  to  marked  my- 
opia, for  example,  prolapse  of  the  vitreous  is  to  be  feared, 
it  is  well  to  instil  a  drop  of  a  3  to  5  per  cent,  solution  of 
cocain  every  three  minutes  for  one-half  hour.  To  pre- 
vent the  cornea  from  getting  dull  and  opaque,  the  eyCis 
covered  with  wet  cotton  while  the  cocain  is  being  instilled. 
[The  editor  prefers  not  to  make  such  frequent  instilla- 
tions of  cocain  ;  in  spite  of  all  precautions  they  tend  to 
cause  opacity  of  the  corneal  epithelium,  and  encourage 
subsequent  collapse  of  the  cornea. — Ed.] 

5.  All  the  attendants  whose  fingers  come  in  contact  with 


129 


130  OPERATIONS  ON  THE  EYE. 

the  operative  field  should  disinfect  their  hands  with  soap, 
hot  water,  a  sterilized  brush,  60  per  cent,  alcohol,  and, 
finally,  bichlorid  of  mercury  and  trichlorid  of  iodin  in 
the  strength  of  1  :  1000.  As,  however,  it  is  not  always 
possible  to  be  quite  certain  that  the  hands  are  sterile,  it  is 
always  best  to  adopt  the  rule  not  to  touch  the  operative 
field  with  the  fingers,  but  only  with  sterile  instruments, 
and  not  only  during  and  after  the  operation  but  also  be- 
fore the  operation,  while  cleansing  the  parts  in  the  manner 
now  to  be  described. 

6.  The  next  step  is  the  cleansing  of  the  operative  field  : 

(a)  All  the  external  skin  covering  the  forehead,  cheek, 
and  nose,  as  far  as  the  edges  of  the  lids,  to  be  washed 
first  with  the  tincture  of  soap  and  hot  water,  then  with 
alcohol,  and  finally  with  a  1  :  1000  solution  of  bichlorid 
of  mercury,  the  cleansing  with  all  these  materials  being 
done  with  cotton  pledgets.  The  preliminary  softening  of 
the  skin  by  the  wet  bandage  materially  facilitates  this 
laving  process. 

The  cleansing  of  the  edges  of  the  lids,  which  must  be 
performed  cautiously  but  thoroughly,  is  of  the  utmost 
importance. 

(6)  Next  the  conjunctival  sac  is  thoroughly  flushed  out 
by  pouring  a  1  :  5000  solution  of  bichlorid  of  mercury  or 
carefully  sterilized  saline  solution  from  a  suitable  vessel 
on  the  everted  lids  and  transition  folds,  rubbing  the  parts 
at  the  same  time  with  small  pledgets  of  sterilized  gauze ; 
or  glass  rods  tipped  with  cotton  may  be  kept  ready  for 
use  as  sterile  sponges,  and  these  may  also  be  used  for 
cleansing  the  conjunctiva  by  thoroughly  wiping  all  the 
folds  of  the  membrane.  After  the  lids  have  been  re- 
placed, the  bulbar  conjunctiva,  the  inner  canthus^nd 
especially  the  region  where  the  cataract  incision  isrto  be 
made,  should  also  be  gently  wiped  off  and  irrigated.  The 
edges  of  the  lids  must  be  once  more  carefully  wiped  off, 
because  the  manipulation  during  eversion  may  have  ex- 
pressed some  of  the  contents  of  the  Meibomian  and  other 
glands  in  the  edge  of  the  lid. 


OPERATION  FOR  SENILE  CATARACT.  131 

If  there  is  a  dacryostenosis  without  so  much  secretion 
as  would  necessitate  extirpation,  the  upper  and  lower 
lacrimal  canaliculi  must  be  closed  with  the  galvano- 
cautery,  as  described  on  page  58,  after  which  the  inner 
canthus  is  once  more  flushed  out.  It  is  important  to  begin 
the  operation  immediately  after  the  cleansing  has  been 
completed,  because  the  cocain  anesthesia  soon  disappears. 
As  the  cleansing  of  the  conjunctival  sac  produces  some 
reddening  of  the  mucous  membrane,  the  anesthesia  rapidly 
disappears  and  can  not  be  maintained  by  the  further  addi- 
tion of  cocain  unless  adrenalin  is  instilled  at  the  same 
time.  The  patient's  head,  especially  the  hairy  scalp, 
having  been  covered  with  sterilized  gauze  so  as  to  leave 
only  the  eye  and  its  immediate  neighborhood  exposed,  and 
the  operator,  having  satisfied  himself  that  the  light  falls 
on  the  operative  field  from  the  right  direction,  and  that 
the  electric  light  is  ready  for  any  emergency — the  latter 
being  the  exclusive  source  of  illumination  on  dull  days — 
each  attendant  takes  up  his  proper  position  and  begins  his 
duties,  and  all  is  then  in  readiness.  As  regards  the  posi- 
tion of  the  operator  and  his  assistants,  it  is. obvious  that 
the  operator,  who  always  stands  at  the  patient's  head  and 
operates  on  the  right  eye  with  the  right  hand  and  on  the 
left  eye  with  the  left  hand,  must  have  the  most  comfort- 
able position.  If  he  is  not  ambidexter  he  will  have  to 
stand  to  the  left  of  the  patient  when  operating  on  the 
left  eye. 

One  practised  assistant  is  indispensable,  and  a  second  is 
much  to  be  desired.  The  former,  who  stands  facing  the 
operator,  manages  the  lids  and,  if  an  iridectomy  is  to  be 
performed,  steadies  the  bulb. 

The  larger  the  corneal  incision  and  the  more  it  resem- 
bles a  flap  incision,  the  more  important  it  is  to  hold  the 
lids  well  apart.  If  a  stop-speculum,  like  those  illustrated 
in  Figs.  9-13,  is  used,  the  assistant  must  hold  it  tightly 
by  its  peripheral  extremity  so  long  as  it  remains  in  the 
eye,  and  keep  it  away  from  the  globe  so  that,  if  the 
patient  winks,  the  lids  will  be  unable  to  exert  injurious 


132  OPERATIONS  ON  THE  EYE. 

Figs.  24-31. — Instruments  required  for  an  operation  on  senile  cataract. 
Other  instruments  of  the  same  kind  may,  of  course,  also  be  used. 

Fig.  24. — von  Gräfe  speculum. 

Fig.  25. — von  Gräfe  fixation-forceps  with  lock. 

Fig.  26. — von  Gräfe  cataract-knife. 

Fig.  27. — Iridectomy  forceps. 

Fig.  28. — Iris  scissors,  curved. 

Fig.  29. — von  Gräfe  cystotome.  The  other  end  of  the  instrument  is 
provided  with  a  metal  scoop,  to  assist  in  the  escape  of  the  cataract. 

Fig.  30. — German-silver  spatula  for  replacing  the  iris,  etc. 

Fig.  31. — Weber  wire-loop. 

Even  when  the  operator  intends  to  extract  without  performing  an 
iridectomy,  the  iridectomy  instruments — forceps  and  scissors — must  be 
kept  in  readiness.  The  combination  of  cystotome  and  scoop  is  not  to  be 
advised,  because  in  using  the  cystotome  the  operator  is  apt  to  touch 
something  with  the  scoop  end.  It  is  better  to  use  the  cystotome  (Fig.  40) 
and  the  scoop  (Fig.  35)  separately. 

The  wire-loop  should  be  laid  out  ready  for  use  at  every  operation. 

pressure  on  the  eye.  Many  operators  prefer  to  have  the 
lids  held  apart  with  single  specula  or  retractors,  as,  for 
example,  Pellier's  instrument  (Fig.  32),  especially  when 
they  operate  without  iridectomy.  Others  merely  have  the 
assistant  draw  the  lids  apart.  In  that  case  the  assistant 
should  cover  the  fingers  that  he  uses  for  that  purpose  with 
sterile  gauze,  to  enable  him  to  get  a  firm  grip  of  the  lids. 
Unless  his  fingers  are  very  slim,  however,  they  are  apt  to 
be  in  the  way,  and,  as  a  rule,  a  properly  handled  lid- 
speculum  is  to  be  preferred. 

If  the  assistant  is  to  hold  the  speculum  in  the  way  that 
I  have  described  he  must  pay  attention  to  the  following 
points:  He  must  not  go  too  far  in  his  effort  to  hold  the 
speculum  away  from  the  eye,  to  protect  the  organ  from 
injurious  pressure  by  the  eyelids  when  the  patient  shuts 
his  eyes  tightly,  for  fear  of  the  instrument  suddenly  and' 
entirely  slipping  out  from  under  the  lids,  especially  when 
the  lids  are  rather  long  and  flaccid,  as  such  an  accident 
would  be  followed  by  unpleasant  consequences.  .Again, 
during  the  delivery  of  the  cataract,  when  slight  pressure 
on  the  globe  may  under  certain  circumstances  be  desirable, 
he  must  relax  his  hold  on  the  speculum,  but  not  relinquish 


133 


134  OPERATIONS  ON  THE  EYE. 

it.  In  order  to  be  able  to  do  do  all  these  things  properly 
the  assistant  who  is  charged  with  this  duty  must  have  a 
firm  footing — for  the  work  he  has  to  do  is  of  a  most  par- 
ticular kind.  The  second  assistant,  who  stands  by  the 
side  of  the  operator,  hands  him  the  instruments,  taking 
great  care  to  avoid  contaminating  any.  If  necessary,  he 
also  looks  after  the  electric  light ;  although  it  is  better  to 
have  this  duty  attended  to  by  some  one  else.  Finally, 
some  one  must  hold  the  patient's  head,  taking  care,  of 
course,  to  keep  his  or  her  hands  under  the  gauze  covering. 

Instruments,  sponges,  dressing-material,  etc.,  should  be 
laid  on  a  small  operating  table,  close  to  the  patient's  head. 
During  the  entire  operation  water  should  be  boiling  in  the 
immediate  neighborhood,  so  that  an  instrument  may  be 
plunged  into  it  at  any  time,  if  necessary  ;  for,  in  spite  of 
the  utmost  precaution,  it  may  happen  to  come  in  contact 
with  something  outside  of  the  sterile  operative  field  and 
have  to  be  at  once  sterilized  again. 

The  patient  lies  on  his  back,  either  on  the  operating 
table  or  on  his  bed,  with  his  head  slightly  raised  and  in  as 
comfortable  a  position  as  possible.  The  operator,  having 
provided  himself  with  a  mouth-mask,  which  I  have  now 
used  for  two  years,  gives  him  the  necessary  instructions, 
telling  him  specially  not  to  hold  his  breath  during  the 
operation  and  not  to  bear  down.  The  mouth-mask  makes 
it  possible  to  talk  to  the  patient  quietly ;  and  if  the  latter, 
as  is  usually  the  case,  is  excited,  this  has  a  very  quieting 
effect,  providing  the  physician  himself  is  cool.  By 
judicious  encouragement  it  is  very  often  possible  to  quiet 
the  patient's  fears  and  remove  all  dread  of  the  operation. 

Nobody  but  the  operator  should  talk  or  give  the  patient^ 
any  instructions,  as  it  would  only  confuse  him. 

[Professor  Haab's  directions  are  so  explicit,  in  so  far  as 
the  preparation  of  the  region  of  operation  and  instru- 
ments are  concerned,  that  additional  comments  may  seem 
superfluous,  but  the  editor  feels  that  the  method  used  by 
himself  and  many  colleagues  is  worthy  of  record  here. 

Referring  especially  to  the  preparation  of  the  eye  itself 


OPERATION  FOR  SENILE  CATARACT.  135 

for  some  days  previous  to  the  operation,  the  editor  be- 
lieves, with  Knapp,  that  it  should  be  protected  from  any- 
thing which  may  produce  congestion,  and  that  the  patient 
should  remain  in  the  hospital,  perfectly  resting  his  eyes 
and  body,  and  frequently  washing  his  face  and  the  surface 
and  margins  of  the  eyelids  with  soap  and  water.  If  there 
should  be  any  discharge  from  the  conjunctiva  and  a 
tendency  of  secretion  to  gather  at  the  commissural  angles, 
an  instillation  of  a  25  per  cent,  solution  of  argyrol,  two 
or  three  times  a  day,  is  of  great  advantage.  During  these 
days  scrupulous  attention  should  be  given  to  the  naso- 
pharynx. In  recent  years  the  editor,  following  a  sugges- 
tion of  J.  A.  Lippincott,  has  been  accustomed  to  spray 
the  nasopharynx  three  times  daily  with  a  solution  of 
permanganate  of  potassium  (1  :  5000)  with  gratifying 
results. 

In  the  preparation  of  the  skin  of  the  region  of  opera- 
tion the  following  plan  is  pursued  :  The  skin  is  treated 
first  with  soap  and  water,  then  with  alcohol,  and  finally 
with  corrosive  sublimate  (1  :  2000).  These  irritating  sub- 
stances are  not  allowed  to  enter  the  conjunctival  sac,  but 
the  face,  surface  of  the  closed  lids,  eyebrows,  brow,  and 
scalp  above  the  brow  are  thus  prepared :  The  ciliary 
margins  are  cleansed  with  soap  and  water,  followed  by 
bichlorid  of  mercury  (1  :  5000).  The  parts  are  kept 
covered  with  a  compress  of  lint  soaked  in  a  bichlorid 
solution  (1  :  5000)  or  in  boric-acid  solution  for  at  least  an 
hour  prior  to  the  operation  and  after  the  preparation  just 
described  has  been  completed. 

Just  preceding  the  operation,  the  preparatory  bandage 
is  removed,  the  ciliary  margins  again  cleansed  with 
bichlorid  of  mercury  (1  :  5000)  with  the  same  precautions 
previously  described.  Next  the  conjunctival  cul-de-sac  is 
flushed  with  a  tepid  solution  of  boric  acid,  applied  with 
some  force,  or  with  a  sterile  physiologic  salt  solution. 
During  these  irrigations,  pressure  should  be  made  over 
the  lacrimal  sac  in  order  to  be  sure  that  no  deleterious 
secretion  is  contained  within  it;  or  its  condition  may  have 


136  OPERATIONS  ON  THE  EYE. 

Plate  2. 

Operation  for  Senile  Cataract :  The  cataract-knife  has  been  carried 
through  the  anterior  chamber,  and  the  incision  is  now  being  made 
upward. 

been  ascertained  previously  by  injecting  it  with  an  Anel 
syringe,  in  the  manner  described  by  Dr.  Haab.  The  lids 
are  then  everted,  the  tarsal  conjunctiva  and  the  region  of 
the  inner  canthus  wiped  with  a  pledget  of  cotton  moistened 
in  boric-acid  solution.  If  there  is  any  suspicious  redness 
in  the  region  of  the  caruncle  at  the  conclusion  of  the 
operation  and  before  the  bandage  is  applied,  this  is  dusted 
with  sterile  iodoform  powder. — Ed.] 

Cataract  Extraction  with  Iridectomy. — For  this 
procedure  the  instruments  illustrated  in  Figs.  24-31  are 
required.  The  speculum  having  been  introduced  and 
locked,  so  as  to  make  it  impossible  for  the  lids  to  close, 
the  globe  is  seized  with  the  fixation-forceps  immediately 
below  the  cornea,  utilizing  a  fold  of  the  conjunctiva  (see 
Plate  2),  and  the  knife,  held  with  the  edge  upward,  is 
introduced  into  the  upper  part  of  the  anterior  chamber, 
making  a  corneal  incision,  the  size  of  which  is  gauged  by 
the  size  of  the  nucleus  of  the  cataract  and  the  size  of  the 
cornea.  The  darker  and  more  yellow  the  nucleus  appears 
through  the  small  quantity  of  cortical  matter,  the  larger 
it  will  be.  If,  on  the  other  hand,  the  cortical  material 
represents  a  thick  layer  surrounding  the  nucleus,  as,  for 
example,  in  young  individuals,  such  a  condition  betrays 
itself  by  the  fact  that  the  grayish,  translucent,  rather 
milky  coloration  extends  deep  into  the  cataract.  The 
diameter  of  the  cornea  also  may  be  quite  variable.  The, 
cornea  may  be  small  without  the  cataract  behind  it  neces- 
sarily being  small  also,  and  in  such  cases  it  is  specially 
important  not  to  make  the  incision  too  small.  The  height 
of  the  flap  must  be  increased,  and  the  incision  must,  if 
possible,  lie  entirely  within  the  scleral  border.  If  the 
cornea  is  large,  as  is  sometimes  the  case  in  myopic  eyes, 
the  flap  need  not  be  so  high  as  shown  in  Plate  2,  espe- 


OPERATION  FOR  SENILE  CATARACT.  137 

cially  if  marked  myopia  is  actually  present.  In  a  myopic 
eye  of  this  kind  it  is  important  to  guard  against  the  loss 
of  any  vitreous  material,  the  danger  of  which  is  greater 
when  the  incision  lies  within  the  scleral  border.  It  is 
therefore  advisable  in  these  cases  to  keep  the  incision 
entirely  within  the  cornea.  It  appears,  therefore,  that  in 
making  the  incision  for  cataract  extraction  it  is  necessary 
to  individualize ;  but  it  is  always  better  to  make  the 
incision  somewhat  too  large  than  too  small. 

Having  carefully  noted  the  points  where  the  instrument 
is  to  enter  and  to  emerge,  the  knife  (which  is  held  like  a 
coffee  spoon)  is  rapidly  carried  through  the  anterior  cham- 
ber, in  doing  which  the  operator  must  not  bear  heavily 
with  his  hand  on  the  patient's  head  and,  if  possible,  should 
not  support  his  hand  at  all.  The  incision  is  then  com- 
pleted by  drawing  the  knife  backward  and  forward — that 
is,  by  a  sawing  movement,  closely  following  the  corneal 
border.  Beginners,  in  making  these  incisions,  often  make 
the  mistake  of  bearing  too  hard  on  the  edge,  and  not 
drawing  the  knife  backward  and  forward  enough.  The 
more  the  edge  of  the  knife  is  drawn  backward  and  for- 
ward against  the  object  to  be  divided,  the  better  the  knife 
will  cut.  This  is  specially  true  of  hard  tough  objects,  of 
which  the  cornea  is  a  very  good  example  ;  for  it  does  not 
belie  its  name.  Only  soft  substances,  like  butter,  or  semi- 
solid material  of  uniform  consistence,  like  paraffin,  can  be 
divided  or  crushed  apart  by  direct  pressure  on  the  edge — 
that  is,  by  using  the  knife  like  a  chisel.  But  in  drawing 
the  knife  backward  and  forward  there  is  danger  in  the 
case  of  deep-set  eyes  of  injuring  the  inner  canthus,  or  the 
upper  margins  of  the  lids,  which  are  not  rendered  insen- 
sitive by  the  cocain.  This  causes  the  patient  to  jerk  and 
wink,  and  in  that  way  escape  of  the  vitreous  immediately 
after  the  incision  has  been  made  becomes  possible.  [The 
wound  margins  will  be  smoother  if,  after  puncture  and 
counter-puncture,  the  knife  is  pushed  steadily  onward  as 
far  as  possible,  with  an  upward  tendency,  and  the  incision 
is  completed  by  a  free  cutting,  not  a  sawing  or  dragging 


138  OPERATIONS  ON  THE  EYE. 

movement,  keeping  the  knife  in  the  same  plane  through- 
out the  procedure. — Ed.] 

From  this  we  deduce  the  important  rule  that,  in  mak- 
ing the  incision,  the  operator  must  keep  his  eve  not  only 
on  the  edge  of  the  knife,  but  also  on  the  point.  The 
other  hand,  which  holds  the  fixation-forceps,  must  also 
be  carefully  controlled  by  the  operator.  If,  as  the  begin- 
ner in  operative  work  is  apt  to  do,  the  surgeon  directs  his 
attention  exclusively  to  the  cutting  hand,  he  is  in  danger 
of  unconsciously  exerting  a  most  injurious  pressure  on 
the  globe  with  the  forceps,  "  by  way  of  emphasis,"  and  as 
a  result  the  knife,  as  it  completes  the  incision,  may  be 
followed  by  the  sudden  escape  of  vitreous.  For  this 
reason  it  is  a  good  plan  to  support  the  hand  which  holds 
the  fixation-forceps  (even  when  that  duty  is  entrusted  to 
the  assistant)  on  the  patient's  upper  jaw  as  the  globe  is 
seized  and  held  fast,  so  that  once  the  proper  position  for 
fixation  has  been  taken,  any  pressure  on  the  point  of  the 
forceps  becomes  absolutely  impossible,  because  the  hand 
or  the  tips  of  the  fingers  rest  against  the  patient's  jaw. 

Another  reason  for  making  the  incision  slowly  is  that 
the  aqueous  humor  ought  not  to  escape  through  the  ante- 
rior chamber  too  rapidly,  because  a  sudden  lowering  of 
the  pressure  favors  the  occurrence  of  intra-ocular  hemor- 
rhage. It  must  not  be  made  too  slowly,  however,  because 
in  that  case  all  of  the  aqueous  humor  escapes,  carrying 
the  iris  with  it  and  bringing  it  in  front  of  the  knife ; 
although,  if  such  an  accident  happens,  the  incision  should 
be  quickly  completed,  for  the  iridectomy  will  then  be  per- 
formed at  the  same  time,  although  not  in  the  regular  way. 

When  it  is  necessary  to  make  a  conjunctival  flap,  the 
customary  upward  rotation  of  the  edge  of  the  knife,  which 
is  performed  as  the  last  fibers  of  the  membrane  are 
divided,  so  as  to  bring  the  knife  out  of  the  tissue  before 
leaving  the  cornea,  is  omitted  and  the  incision  is  continued 
a  little  farther  in  the  direction  of  the  sclera,  under  the 
conjunctiva,  which  is  loosely  attached  to  that  membrane. 
The  knife  is  thus  carried  some  little  distance  under  the 


OPERATION  FOR  SENILE  CATARACT.  139 

conjunctiva  before  it  is  rotated  upward  and  brought  out 
of  the  tissue.  In  order  to  prevent  the  conjunctival  flap 
from  becoming  a  disturbing  factor  in  the  iridectomy,  it 
should  be  at  once  turned  back  over  the  cornea  with  the 
point  of  the  knife,  as  otherwise  it  is  apt  to  be  cut  off  along 
with  the  iris. 

The  next  step  is  the  iridectomy.  The  fixation-forceps 
is  handed  over  to  the  assistant,  who  gently  rotates  the 
globe  downward,  enabling  the  operator  to  introduce  the 
curved  iris-forceps  and  seize  the  membrane.  The  forceps 
is  introduced  closed  and  carried  near  the  edge  of  the 
pupil ;  it  is  then  opened  a  little,  gently  inserted  into  the 
iris,  closed  again,  and  drawn  out  of  the  wound,  so  that  the 
iris  can  be  cut  off  with  a  single  snip  of  the  scissors,  the 
curved  blades  of  the  iridectomy-scissors  being  pressed 
firmly  against  the  wound.  It  is  not  necessary  to  excise 
a  large  section  of  the  iris  in  operating  for  cataract. 

After  the  iridectomy  the  capsule  of  the  lens  is  opened. 
The  cystotome,  with  the  blunt  part  foremost,  having  been 
introduced  into  the  pupillary  region,  lacerations  are  made 
with  the  sharp  point  of  the  instrument  from  the  lower 
edge  of  the  pupil  upward  almost  to  the  wound,  as  well  as 
crosswise,  so  as  to  lacerate  the  capsule.  The  knife  should 
not  be  introduced  deep  into  the  lenticular  substance,  so  as 
to  touch  the  nucleus  and  displace  it.  The  instrument 
must  be  sharp,  in  order  not  to  catch  in  the  capsule  and 
cause  luxation  of  the  entire  cataract  when  traction  is  made 
on  the  instrument.  It  must  not  act  like  a  blunt  hook, 
pulling  on  the  capsule  and  tearing  the  zonule  of  Zinn, 
thus  producing  a  prolapse  of  the  vitreous. 

Whenever,  therefore,  as  happens  in  the  case  of  over- 
ripe or  complicated  cataracts,  the  anterior  capsule  is 
thickened  at  its  center  and  shows  the  senile  capsular  cata- 
ract, which  is  recognized  by  a  paler  or  even  a  white  dis- 
coloration, it  is  better,  in  opening  the  capsule,  to  cut 
around  the  thickened  capsule  with  the  knife,  completing 
its  removal  with  the  forceps  before  proceeding  with  the 
delivery  of   the   cataract.     The   thickened  capsule   may 


140  OPERATIONS  ON  THE  EYE. 

Plate  3. 

Reposition  of  the  iris  with  the  spatula  at  the  end  of  an  operation  for 
senile  cataract.  The  gauze  with  which  the  parts  around  the  eye  are 
covered  is  not  shown  in  the  picture. 


also  be  seized  and  lifted  out  with  specially  devised  cap- 
sule-forceps (Figs.  44  and  46).  In  fact,  some  operators 
prefer  to  open  the  capsule  with  the  capsule-forceps  in 
every  case,  because  a  large  piece  of  the  anterior  capsule 
is  thus  entirely  removed,  and  the  cause  of  secondary  cata- 
ract is  in  part  obviated.  Unless  the  forceps  is  very  well 
made,  however,  and  is  delicately  and  ably  handled,  the 
operator  is  very  apt  to  tear  the  zonule  of  Zinn,  either  by 
pressing  on  the  cataract  as  he  seizes  the  capsule,  or  by 
dragging  on  the  capsule  as  he  tears  it  out,  and  thus  cause 
prolapse  of  the  vitreous. 

After  the  capsule  has  been  opened,  the  delivery  of  the 
cataract  is  a  comparatively  simple  matter.  The  operator, 
who  has  resumed  the  fixation-forceps  after  completing  the 
iridectomy,  exerts  moderate  pressure  on  the  globe  with 
the  instrument  and  thus  forces  the  lower  edge  of  the  cata- 
ract somewhat  backward.  As  a  result  the  upper  border 
is  tilted  slightly  forward  and  enters  the  corneal  wound. 
To  complete  the  delivery  of  the  cataract  the  operator 
resorts  to  a  suitable,  curved,  spoon-like  instrument  (Fig. 
29),  preferably  made  of  glass  (Fig.  35),  which  he  carries 
across  the  cornea  from  below  upward,  exerting  more  or 
less  pressure,  and  thus  stripping  out  the  cataract.  Usu- 
ally part  of  the  soft  cortical  matter  escapes  first,  the 
nucleus  then  presents  and  slips  out,  followed  by  remains 
of  the  cataract  consisting  of  cortical  matter  ;  or  fragments 
of  the  nucleus  are  stripped  out  in  a  similar  manner  until 
the  pupillary  region  appears  to  be  as  clean  as  possible — 
that  is,  black. 

This,  however,  does  not  end  the  operation.  The  iris, 
which  is  usually  pushed  into  the  wound  during  the 
delivery  of  the  cataract,  must  be  freed,  and  replaced  as 
nearly  as  possible  in  its  normal  position.     The  iris  must 


j 


OPERATION  FOR  SENILE  CATARACT.  141 

never  be  allowed  to  stay  in  the  wound  during  an  opera- 
tion, and  this  principle  applies  to  operations  on  cataract 
also.  With  the  spatula  (Fig.  30),  therefore,  the  iris, 
which  lies  in  the  angles  of  the  wound,  is  carefully  replaced 
by  carrying  the  instrument  cautiously  from  the  angle  of 
the  wound  toward  the  center  and  slightly  inward  toward 
the  pupil  (see  Plate  3),  so  that  the  corners  of  the  sphinc- 
ter occupy  their  normal  positions. 

Allowing  the  iris  to  remain  within  the  wound  also,  has 
the  following  disadvantages  :  (1)  The  pupil  is  too  high, 
which  is  undesirable,  because  only  the  central  portion 
of  the  cornea  possesses  the  curvature  necessary  to  form  a 
sharp  retinal  image.  (2)  Astigmatism  increases  after  the 
operation,  because  the  iris  is  caught  in  the  scar  and  pre- 
vents the  cornea  from  regaining  its  normal  curvature, 
which  is  for  a  time  impaired  by  the  cataract  incision. 
(3)  The  possibility  of  iritis  following  the  operation  is 
greater  when  the  iris  is  caught  in  the  scar.  (4)  The  ten- 
dency to  increased  intra-ocular  tension  (glaucoma)  is 
greater  for  all  time  in  an  eye  of  this  kind.  (5)  If  the 
adhesion  of  the  iris  is  large,  as  is  apt  to  be  the  case,  and 
increases  as  healing  progresses,  it  becomes  a  permanent 
disability,  because  a  scar  that  contains  a  portion  of  the 
iris  may  become  the  port  of  entry  for  an  infection,  which 
in  a  short  time  may  lead  to  panophthalmia,  and  therefore 
to  loss  of  the  eye,  unless  the  infection  can  be  removed 
with  iodoform,  as  has  been  mentioned  elsewhere  in  this 
work. 

If  some  tissue  remains  behind  after  the  escape  of  the 
cataract,  especially  in  the  region  of  the  pupil,  an  attempt 
may  be  made  to  strip  it  out,  not  as  was  formerly  done 
with  the  aid  of  the  lower  lid,  because  the  edge  of  the  lid 
is  apt  to  cause  infection  of  the  wound,  but  with  the  same 
instrument  that  is  used  for  the  delivery — namely,  a  glass 
spatula  (Fig.  35),  hard-rubber  or  metal  spoon  (Figs.  29 
and  39),  or  the  like.  The  remains  of  these  lenticular 
masses  must,  however,  not  be  scraped  out  too  energetically, 
because  there  is  danger  of  injuring  the  cornea  and  espe- 


142  OPERATIONS  ON  THE  EYE, 

dally  of  causing  prolapse  of  the  vitreous.  Whatever  can 
not  be  removed  with  this  method  without  using  undue 
force  had  better  be  allowed  to  remain.  Such  material 
often  consists  of  sticky  portions  of  the  cortex,  which  ad- 
here to  the  capsule  and  can  only  be  driven  out  by  using 
injudicious  pressure ;  besides,  they  readily  undergo  ab- 
sorption later,  if  the  eye  is  not  inflamed.  Now  that  we 
are  not  afraid  of  making  a  large  incision  for  the  extraction, 
the  stripping  out  of  cataractous  remains  is  not  as  important 
a  matter  as  it  was  during  the  period  when  Gräfe's  short 
incision  was  in  vogue. 

In  concluding  the  operation  the  corners  of  the  iris  are 
once  more  inspected  and,  if  necessary,  the  iris  is  once 
more  replaced,  and  finally,  the  operative  field  is  thoroughly 
cleansed  of  blood  and  the  remains  of  the  cataract.  The 
blood,  which  is  usually  clotted  and  adheres  to  the  wound 
in  shreds,  should  be  removed  with  the  iris-forceps  (Fig. 
27).  In  doing  so  the  operator  sees  that  the  conjunctival 
flap,  if  he  has  made  one,  is  in  the  proper  position  and,  if 
necessary,  replaces  it  with  the  spatula  ;  for  the  flap  must 
not  be  turned  back  and  lie  in  the  wound  at  any  point. 
The  eye  is  then  bandaged  and  the  after-treatment,  which 
will  be  mentioned  again,  begins. 

Operation  for  Senile  Cataract  without  Iridec- 
tomy.— This  is  also  called  the  simple  cataract  operation, 
and  the  same  instruments  are  required  ;  for  the  iridectomy- 
forceps  and  scissors  must  always  be  ready  at  hand  when 
this  method  is  employed,  because  the  operator  is  never 
certain  that  excision  of  the  iris  will  not  be  necessary.  A 
good  many  operators  prefer  to  use  a  single  speculum  in- 
stead of  the  stop-speculum  in  this  method  of  extracting 
the  cataract,  especially  a  Pellier  (Fig.  32)  or  a  Noyes 
speculum  (Fig.  18),  which  take  up  less  space.  Or  they 
merely  ask  the  assistant  to  hold  the  lids  apart  with  the 
fingers,  protected  with  gauze.  If  a  stop-speculum  is  used 
with  this  operation,  the  assistant  must  exercise  great  care 
to  keep  the  blade  under  the  upper  lid  slightly  away  from 
the  globe  whenever  the  patient  tries  to  wink.     This  is 


OPERATION  FOR  SENILE  CATARACT.  143 

particularly  necessary  after  the  incision   has  been  made, 
when  the  danger  of  prolapse  of  the  vitreous  begins. 

If  the  stop-speculum  is  properly  managed  it  is,  according  to  my  ex- 
perience, practically  impossible  for  the  patient  to  produce  prolapse  of 
the  vitreous  by  compressing  the  lids,  both  when  iridectomy  is  used  and 
when  the  cataract  is  extracted  without  iridectomy  ;  it  is  even  possible  to 
use  stop-specula  which  are  held  open  by  means  of  a  screw  (Figs.  9-13). 
If  the  assistant  possesses  the  necessary  skill  he  will,  as  a  rule,  have 
plenty  of  time  to  remove  this  instrument  from  the  eye.  Certain  in- 
genious mechanisms  have  been  devised  in  the  construction  of  the  instru- 
ment for  the  purpose  of  making  it  possible  to  remove  it  suddenly  from 
the  eye  in  case  of  threatening  prolapse  of  the  vitreous.  Instead  of  a 
screw,  Landolt  has  a  small  lever  (Fig.  34)  which  can  be  pushed  back 
and  forth  with  the  finger.  This  locks  the  speculum  when  it  is  dropped 
into  a  small  ratchet,  and  allows  it  to  open  again  when  it  is  raised. 
Mellinger's  (Fig.  13)  and  Roster's  (Fig.  12)  instruments  are  even  more 
simple  in  their  construction ;  for,  while  closure  of  the  eyes  is  rendered 
impossible,  although  there  is  no  stop-screw,  the  instrument  can  be  at 
once  closed  and  removed  simply  by  compressing  the  handles  and  thus 
approximating  the  arms  of  the  speculum.  Unfortunately,  these  two 
specula  sometimes  draw  the  lids  farther  apart  than  is  necessary. 

In  using  a  stop-speculum  the  assistant  should  stand  on  the  same  side 
of  the  patient  as  the  eye  to  be  operated  upon ;  but  if  the  lids  are  held 
apart  with  Pellier's  hooks  or  with  the  fingers,  the  assistant  should  stand 
on  the  opposite  side.  In  the  former  case  his  position  is  also  the  best  in 
case  an  iridectomy  becomes  necessary.  If  the  operator  takes  up  his 
position  on  the  patient's  left  side  while  he  is  operating  on  the  left  eye, 
the  assistant  must  stand  at  the  patient's  head.  This  arrangement  should 
;ilso  he  adopted  for  extraction  with  iridectomy.  The  assistant  should 
grasp  the  peiipheral  end  of  the  speculum  firmly  with  the  thumb, 
second,  and  third  fingers  of  the  right  hand,  and  keep  it  slightly  away 
from  the  globe.  At  the  same  time  he  must  take  care  not  to  hold  it 
too  far  away  ;  otherwise,  if  the  lids  are  flaccid  and  long,  the  arms  of  the 
instrument  may  suddenly  slip  out  from  under  them.  As  the  arms  are 
usually  curved,  the  hand  in  which  the  speculum  is  held  can  be  kept 
to  one  side  of  the  patient's  head  so  as  not  to  interfere  with  the  operator. 

The  simple  operation  is  performed  in  the  same  way  as 
when  iridectomy  is  also  used,  except  that  the  flap  is  made 
somewhat  larger  by  inserting  the  instrument  into  the 
cornea  and  emerging  again  near  the  horizontal  meridian 
of  the  membrane — i.  e.,  when  the  lens  is  extracted  from 
above,  a  little  deeper  than  shown  in  Plate  2.  When  this 
method  is  used,  the  cataract  can,  of  course,  also  be  ex- 
tracted from  below,  and  the  latter  method  would  be  easier 
in  the  case  of  patients  wdio  find  it  hard  to  look  down. 


144  OPERATIONS  ON  THE  ÜYE. 

Fig.  32.— Pellier  speculum. 

Fig.  33. — Laug  speculum. 

Fig.  34. — Landolt  speculum. 

Fig.  35. — Pagenstecher  glass  spatula  (manufactured  by  Müller,  Wies- 
baden). 

Fig.  36. — Desmarres  knife  with  a  blunt  point  for  the  cataract  in- 
cision. 

Fig.  37. — Narrow  wire-loop,  after  Snellen. 

Fig.  38. — Broad  wire-loop,  after  Weber. 

But  as  one  can  never  know  for  certain  that  an  iridectomy 
will  not  be  necessary,  it  is  customary  to  make  the  incision 
above,  because  an  upper  incision  is  protected  by  the  upper 
lid  and  during  the  period  of  healing  is  not  quite  so  near  the 
palpebral  margin,  which  is  never  above  the  suspicion  of 
infection. 

The  size  of  the  flap  must,  however,  be  gauged  more  or 
less  by  the  probable  size  of  the  nucleus  and  that  of  the 
cornea.  If  the  latter  is  small,  the  flap  must  include  one- 
half  the  membrane,  the  incision  coinciding  with  the 
scleral  border;  if  the  cornea  is  large,  or  the  nucleus 
which  is  to  be  expected  is  small,  the  base  of  the  flap  may 
be  a  little  above  the  center  of  the  pupil  and  the  curved 
incision  just  within  the  corneal  tissue.  It  is  specially 
important  and  desirable  when  operating  without  iridec- 
tomy to  make  the  wound  rather  too  large  than  too  small. 
For  if  the  cataract  escapes  easily,  without  crushing  the 
iris  and  forcing  it  into  the  wound,  there  is  a  reasonable 
expectation  that  no  prolapse  of  the  iris  will  take  place. 

After  seizing  the  globe  with  the  fixation-forceps  near 
the  lower  border  of  the  cornea  (see  Plate  2),  the  operator 
quickly  makes  a  mental  note  of  the  point  of  entrance  and 
exit  for  the  knife.  To  impress  these  points  on  his  mind, 
especially  if  he  has  not  had  a  great  deal  of  experienc,  he 
should  lay  the  cataract  knife  for  an  instant  across  the 
cornea  so  that  the  back  of  the  knife  is  just  in  front  of  the 
horizontal  diameter.  He  may  also  utilize  this  moment  to 
make  sure  that  the  edge  of  the  knife  is  directed  upward 
and  not  downward,  a  mistake  that  is  easily  made,  because 
the  knife  has  such  a  narrow  blade. 


35 


10 


145 


146  OPERATIONS  ON  THE  EYE. 

When  a  large  flap  incision  of  this  kind  is  made  the 
operator  must  be  particularly  careful  to  draw  the  knife 
backward  and  forward,  and  not  exert  too  much  pressure 
on  the  edge  while  completing  his  incision.  Or  he  should 
follow  the  edge  of  the  cornea,  and  keep  as  much  as  pos- 
sible in  the  same  plane  of  section,  and  when  he  reaches 
the  upper  margin  he  should  cut  a  moderately  large  con- 
junctival flap.  To  do  this  the  edge  of  the  knife,  instead 
of  being  turned  sharply  forward,  is  allowed  to  enter  the 
sclera,  and  the  incision  continued  a  little  longer,  so  that 
the  edge  emerges  under  the  conjunctiva,  which  in  old 
persons  is  not  so  firmly  adherent  to  the  sclera  and,  as  a 
rule,  is  lifted  up  by  the  knife.  It  is  then  carried  a  little 
farther  in  the  same  direction,  depending  on  the  width  of 
the  flap  which  it  is  desired  to  make,  and  turned  sharply 
upward  so  as  quickly  to  divide  the  conjunctiva. 

Most  of  the  adherents  of  the  simple  extraction  lay  a  great  deal  of 
stress  on  the  conjunctival  flap,  on  the  ground  that  it  favors  rapid  union 
of  the  wound  and  thus  helps  to  prevent  subsequent  prolapse  of  the  iris. 
Some  operators  also  praise  it  as  being  a  protection  against  infection. 
In  my  own  opinion  it  is  best  not  to  place  too  much  dependence  upon  its 
advantages,  although  it  can  not  be  denied  that  they  are  altogether  lack- 
ing when  a  conjunctival  flap  is  made ;  but  any  favorable  influence  it 
may  have  on  the  healing  process  should  be  regarded  only  as  one  of  the 
factors  in  bringing  about  smooth  recovery.  A.  von  Gräfe,  who  also  used 
this  flap  in  his  modified  linear  extraction,  carefully  investigated  its  value 
and  advised  against  making  a  broad  flap.  Czermak's  comprehensive 
critical  review  also  shows  that  a  broad  conjunctival  flap  may  interfere 
with  rapid  union  of  the  corneoscleral  edges  of  the  wound;  for  the 
bridging  of  the  tissue  by  the  conjunctival  flap  destroys  the  marginal 
layer  of  epithelial  cells,  which,  as  we  know,  rapidly  fills  in  the  gap  in  a 
corneal  or  corneoscleral  wound,  and  therefore  materially  aids  in  bring- 
ing about  primary  union.  Instead,  the  marginal  zone  of  epithelium 
lies  farther  back,  at  the  edge  of  the  flap.  "  At  first,  closure  of  the 
wound  is  effected  solely  by  adhesion  between  the  edges  of  this  flap, 
until  the  combined  corneoscleral  wound  has  been  closed  by  cicatricial 
tissue,  which  bridges  it  over  and  then  contracts  it ;  but  the  latter  process 
does  not  begin  until  the  fourth  day."  It  is  therefore  better,  if  a  con- 
junctival flap  is  to  be  used  at  all,  not  to  make  it  more  than  2  to  3  mm. 
wide. 

After  the  cataract  incision  has  been  made,  instead  of 
doing  an  iridectomy,  the  operator  at  once  opens  the  cap- 
sule with  Gräfe's  knife  or  some  other  cystotome,  making 


OPERATION  FOR  SENILE  CATARACT.  147 

a  thorough  crucial  or  Y-shaped  incision,  at  the  same  time 
being  careful  not  to  tear  the  zonule  or  displace  the  nucleus. 
[Peripheral  opening  of  the  capsule  is  preferred  by  some 
operators,  as  such  a  procedure  lessens  the  danger  of  the 
formation  of  posterior  synechia?.  Practically  always  a 
subsequent  laceration  of  the  capsule — discission — will  be 
required. — Ed.] 

After  capsulotomy  the  cataract  is  delivered  in  the  same 
way  as  in  the  operation  with  iridectomy,  except  that,  as 
the  cataract  passes  through  the  pupil,  the  iris  is  also 
pushed  forward  more  or  less ;  but  unless  it  has  been 
firmly  pressed  into  the  wound  it  usually  drops  back  into 
its  normal  position,  sometimes  not  without  slight  assist- 
ance with  the  spatula.  If  it  fails  to  return,  so  that  the 
pupil  is  no  longer  circular  and  is  not  at  the  right  place,  a 
delicate  sound  (Fig.  82)  must  be  introduced  into  the 
wound,  and  the  iris  carefully  freed  and  enabled  completely 
to  return  to  its  normal  position.  If  this  attempt  fails, 
and  the  pupil  remains  eccentrically  displaced  upward,  it 
is  better  to  make  a  secondary  iridectomy. 

As  regards  stripping  out  the  cataractous  remains  sur- 
rounding the  hard  nucleus,  it  is  best  to  do  so  rapidly  and 
immediately  after  the  escape  of  the  nucleus,  so  that  the 
iris  will  not  remain  long  in  the  wound.  Generally  speak- 
ing this  can  not  be  done  so  thoroughly  when  no  iridectomy 
is  performed,  because  the  iris  gets  in  the  way.  If  the 
remaining  tissue  is  very  small  in  amount  it  is  better  to 
leave  it  alone ;  if  the  fragments  are  large  an  attempt  may 
be  made  to  remove  them  with  a  Critchett  scoop  (Figs.  48 
and  49) ;  but  if  in  the  end  any  considerable  quantity  of 
material  remains  behind,  it  is  better  to  do  a  secondary 
iridectomy,  when  the  remains  may  be  removed  by  expres- 
sion or  with  the  scoop. 

Quite  recently  flushing  the  anterior  chamber  and  capsular  sac,  which 
was  in  vogue  during  the  eighteenth  century,  but  was  later  given  up 
again  as  being  too  dangerous  (Guerin,  1773,  see  Magnus),  has  again 
been  recommended  as  a  painless  and  effective  method  of  removing 
cataractous  remains  from  the  eye.  M'Keown,  Lippincott,  Schiess,  and 
Mellinger    (according   to  Rothlisberger's  and   Erb's  communications) 


148  OPERATIONS  ON  THE  EYE. 

have  recently  given  much  attention  to  the  technic  of  this  method, 
using  it  in  a  considerable  number  of  cataract  operations.  M'Keown's 
method  was  recently  used  by  R.  H.  Elliott,  in  Madras,  on  800  cases, 
and  he  warmly  recommends  it.  In  this  method  the  irrigating  fluid  is 
contained  in  a  glass  bottle  with  a  double  bulb,  and  is  forced  through  a 
short  rubber  tube  into  a  glass  point  attached  to  the  latter.  In  his  book, 
M'Keown  gives  an  accurate  description  of  the  method  that  developed, 
especially  for  the  operation  on  unripe  cataracts,  and  used  in  148  cases. 
Lippincott  reports  100  operations  of  this  kind.  He  uses  a  glass  irri- 
gator, which  is  simply  raised  to  get  the  action  of  gravity,  the  fluid 
being  conducted  through  a  glass  point.  In  the  238  cases  reported  by 
Röthlisberger,  Schiess  used  a  Wicherkiewicz  "  undine,"  modified  by 
Uhle;  and,  finally,  Erb  constructed  a  glass  syringe,  which  has  the 
advantage  of  being  more  readily  sterilized.  It  is  needless  to  say  that 
these  irrigating  instruments  must  all  be  absolutely  free  from  germs,  a 
point  insisted  upon  also  by  M'Keown.  His  apparatus,  which  may  be 
obtained  from  John  Clarke  &  Company,  Belfast,  Dublin,  can  also  be 
completely  sterilized  by  boiling.  With  regard  to  the  fluids  that  may 
be  employed  in  this  method  of  irrigating  the  anterior  chamber,  it  fol- 
lows from  what  has  been  said  on  p.  (59,  that  any  solution  in  the  least 
injurious  to  the  tissues,  particularly  bichlorid  of  mercury,  or  carbolic 
acid,  and  the  like,  and  even  distilled  water,  must  be  avoided  ;  for  even 
distilled  water  is  slightly  injurious  to  the  endothelium  of  Descemet's 
membrane.  It  has  been  found,  however,  as  the  result  of  accurate 
investigations  made  by  Mellinger,  and  of  innumerable  clinical  observa- 
tions, that  simple  physiologic  saline  solution,  or  a  3  to  4  per  cent,  solu- 
tion of  boric  acid  is  very  well  borne  by  the  anterior  chamber.  All  the 
authors  cited  agree  that  this  method  of  flushing  out  the  anterior  cham- 
ber is  the  least  injurious,  and  the  best  means  of  removing  cataractous 
remains  from  the  eye.  It  is  also  said  to  facilitate  reposition  of  the  iris, 
both  after  iridectomy  and  after  operation  without  iridectomy.  Irriga- 
tion may  also  be  a"  great  advantage  in  cases  of  traumatic  cataract. 
Suction  has  also  been  employed  for  the  removal  of  soft  cataractous 
masses  through  a  small  corneal  wound ;  this  procedure  is  not  free  from 
danger,  and  may  only  be  employed  with  a  syringe  that  can  be  well 
sterilized,  as  for  example,  Lang's  syringe,  made  for  this  special  purpose 
by  Bowman,  and  obtainable  from  Weiss  in  London. 

Modifications  of  the  Operation  for  Senile  Cata- 
ract.— Modifications  have  been  introduced  at  various 
stages  of  the  operation  for  cataract  extraction  to  insure  a 
better  subsequent  course  and  a  smoother  recovery,  as  well 
as  for  the  purpose  of  adapting  one's  self  to  individual 
variations,  either  in  the  eye  or  in  the  patient. 

1.  English  operators  in  India,  who  practise  largely  on 
cataracts,  among  them  Elliot  and  Pope,  prefer  to  open  the 
capsule  before  making  the  corneal  incision.     The  capsule 


OPERATION  FOR  SENILE  CATARACT.  149 

is  opened  with  Bowman's  needles,  which  are  inserted  at 
the  scleral  margin  in  order  to  prevent  as  much  as  possible 
the  escape  of  aqueous  humor.  They  dwell  on  the  advan- 
tage possessed  by  this  procedure  of  enabling  the  operator 
to  see  accurately  what  he  is  doing,  unhindered  by  any 
flow  of  blood,  which  often  renders  opening  of  the  capsule 
difficult.  At  the  same  time  this  method  enables  the 
operator,  before  he  makes  the  incision,  to  determine  the 
structure  of  the  cataract,  the  size  of  the  nucleus,  and  the 
condition  of  the  cortex,  whether  it  be  soft  or  flabby. 

During  a  period  covering  a  number  of  years  I  have 
occasionally  employed  this  method  in  the  case  of  juvenile 
cataracts  in  order  to  find  out  whether  a  small  (line) 
or  large  (curved)  incision  would  be  required  to  remove 
the  cataract,  and  it  is  quite  true  that  in  the  case  of  senile 
cataract  also  the  method  does  possess  the  advantages 
which  have  been  claimed  for  it. 

2.  Some  operators,  particularly  the  French,  open  the 
capsule  with  the  point  of  the  knife  as  they  carry  it  through 
the  anterior  chamber.  This  procedure  has  a  certain  value 
in  cases  in  which  it  is  desirable  to  terminate  the  operation 
as  rapidly  as  possible. 

3.  Many  operators  prefer  to  tear  out  a  piece  in  the 
pupillary  region  with  the  so-called  capsule-forceps  (Figs. 
44  and  46)  when  they  open  the  lens  capsule.  The  instru- 
ment, which  is  very  much  like  an  iris-forceps,  must  be 
armed  with  teeth  set  obliquely  and  with  the  points  down- 
ward. When  the  forceps  is  applied  to  the  lens  with 
gentle  pressure,  in  the  same  way  as  when  the  iris  is  seized 
prior  to  iridectomy,  the  teeth  bury  themselves  some  dis- 
tance in  the  tissue  of  the  lens  and,  as  the  forceps  is  closed, 
the  capsule  is  caught  by  the  teeth  and  torn  out  and  may  be 
completely  removed,  so  that  afterward  there  is  nothing 
left  of  the  capsule  and  its  epithelial  cells  in  the  pupillary 
region,  and  these  structures  can  not,  therefore,  help  to 
cause  a  secondary  cataract. 

This  procedure  requires  a  very  steady  hand  and  a  pair 
of  forceps  of  perfect  workmanship,  if  it  is  to  be  carried 


150  OPERATIONS  ON  THE  EYE. 

Fig.  39. — v.  Gräfe  cystotome  with  hard-rubber  scoop. 

Fig.  40. — v.  Gräfe  cystotome  without  the  scoop,  better  than  the  above 
combination. 

Fig.  41. — Cataract  needle,  without  stop,  for  cystotomy,  secondary 
cataract  operations,  etc. 

Fig.  42. — Schweigger  cystotome. 

Fig.  43. — Cystotome  of  Weiss,  London. 

Fig.  44. — Wicherkiewicz  capsule-forceps. 

Fig.  45. — Couper  capsule-forceps. 

Fig.  46. — Treacher  Collins  capsule-forceps. 

out  correctly  and  without  doing  any  damage ;  otherwise 
the  zonule  is  apt  to  be  torn  and  cause  subsequent  prolapse 
of  the  vitreous. 

If  the  anterior  capsule  is  thickened  at  the  center,  as 
occurs  in  cataracts  that  are  somewhat  over-ripe,  the 
removal  of  the  thickened  portion  may  be  a  distinct  advan- 
tage, if  it  can  be  effected  without  dislocating  the  entire 
lens.  A  more  cautious  procedure,  however,  is  to  make 
a  circular  incision  around  the  thickened  portion  before 
lifting  it  out.  For  this  procedure  Snellen  recommends  a 
fine,  round  needle,  the  extreme  point  of  which  is  bent 
over  at  an  angle  of  90°.  With  such  an  instrument  he 
claims  it  is  possible  to  scratch  and  divide  the  capsule  in 
every  direction,  while  Gräfe's  cystotome  permits  the 
operator  only  to  cut  upward  and  downward.  When 
Snellen  uses  this  instrument  to  make  the  ordinary  crucial 
incision  for  opening  the  capsule,  he  makes  a  vertical  incis- 
ion from  above  downward,  so  as  not  to  displace  the 
nucleus  upward  and  thus  draw  it  behind  the  wound. 

When  there  is  some  difficulty  about  opening  the  capsule, 
because  the  cataract  is  over-ripe  and  shrunken  and  the 
thickened  capsule  adheres  with  abnormal  tenacity  to  its 
contents,  it  is  better  to  extract  the  cataract  along  with  the 
capsule,  and  not  attempt  to  open  the  latter  at  all. 

4.  Extraction  of  the  cataract  with  the  capsule,  a  method 
which  has  been  chiefly  developed  and  successfully  used  by 
A.  and  H.  Pagenstecher,  is  specially  adapted  for  over-ripe 
cataract,  which  possesses  an  atrophic  zonule  of  Zinn  (see 
p.   86),  so  that  the  cataract  is  apt  to  become  separated 


39         40 


151 


152  OPERATIONS  ON  THE  EYE. 

in  toto  from  its  suspensory  ligament.  Atrophy  of  the 
zonule  is  also  observed  in  Morgagnian  cataract  and  in 
cataracts  that  have  already  contracted.  Dislocated  and 
calcified  cataracts  are  also  best  removed  without  opening 
the  capsule. 

Ordinarily,  the  fact  of  a  cataract  being  over-ripe  is 
recognized,  aside  from  the  possible  presence  of  a  capsular 
cataract,  by  the  uniform  gray  or  grayish-yellow  cloudiness 
of  the  anterior  cortical  layer,  it  being  impossible,  even 
with  oblique  illumination,  to  make  out  any  sharply  defined 
markings. 

The  great  advantage  of  this  method  of  operating  is 
that  the  entire  lens  is  removed  from  the  eye  clean,  without 
leaving  any  remains,  while  its  disadvantage,  which  must 
not  be  overlooked,  is  that  more  or  less  vitreous  is  always 
lost ;  for  such  a  loss  is  apt  to  occur,  or  at  least  threatens 
to  occur,  in  most  cases.  By  thorough  cocainization  this 
accident  can,  however,  be  confined  within  narrow  limits. 
As  this  operation  is  never  performed  without  at  least 
opening  the  vitreous  space,  it  is  particularly  important  to 
make  sure  of  as  perfect  asepsis  as  possible.  The  incision 
(according  to  A.  Pagenstecher)  must  always  be  made  at 
the  corneoscleral  margin,  and  the  conjunctival  flap  must 
not  be  omitted.  The  incision  must  be  just  large  enough 
to  make  it  possible  to  remove  the  lens  in  the  given  case 
without  any  special  difficulty  ;  the  smaller  the  better;  but 
not  too  small  and  not  larger  than  one-third  of  the  circum- 
ference of  the  cornea.  Cataracts  that  have  a  large  amount 
of  soft  and  semifluid  cortical  matter  may  be  removed 
through  smaller  incisions  than  cataracts  with  a  large  firm 
nucleus  (Cataracta  nigra).  Iridectomy  should  always  be 
performed,  and  the  two  edges  of  the  iris  section  freed 
from  the  corners  of  the  wound  and  replaced  as  shown  in 
Plate  3.  Pagen  stech  er's  curet  (Fig.  51)  is  introduced  be- 
hind the  upper  border  of  the  lens,  at  first  in  a  vertical 
direction ;  the  handle  is  then  depressed,  and  the  instru- 
ment carried  forward  a  little  farther,  but  never  beyond 
the  posterior  pole  of  the  lens.     The  assistant  makes  gentle 


OPERATION  FOR  SENILE  CATARACT.  153 

pressure  on  the  lower  border  of  the  cornea  with  a  glass 
spatula  (Fig.  35),  and  gently  and  steadily  pushes  the  lens 
upward  until  it  presents  in  the  wound. 

This  operation  is  not  adapted  to  cases  in  which  the  ten- 
sion of  the  vitreous  body  after  the  incision  and  the  iridec- 
tomy continues  high,  nor  when  the  patient  is  very  rest- 
less. 

5.  Subconjunctival  extraction,  which  was  practised  at 
the  beginning,  middle,  and  end  of  the  last  century  by  a 
few  operators  (Alexander,  1825;  Desmarres,  1851  ;  von 
Hasner,  1873;  Pansier  and  Vacher,  1899),  has  been 
recommended  lately  by  Czermak  for  cases  in  which  there 
is  danger  of  loss  of  the  vitreous,  either  during  the  opera- 
tion, owing  to  dementia,  excitement,  dislocation  of  the 
lens  into  the  anterior  chamber,  over-ripeness,  and  the  like ; 
or  after  the  operation  from  gaping  of  the  wound  (great 
restlessness,  epilepsy,  violent  paroxysms  of  coughing,  etc.). 
The  procedure  consists  in  making  a  broad  conjunctival 
flap  with  the  base  above,  which  is  not  divided  posteriorly, 
so  that  the  edge  of  the  corneal  wound  is  connected  with 
the  equatorial  conjunctiva  by  a  broad  bridge  of  conjunc- 
tival tissue.  This  makes  it  impossible  for  the  wound  to 
gape ;  at  the  same  time,  however,  it  is  more  difficult  to 
excise  the  cataract  under  the  conjunctival  bridge.  The 
latter  should  be  made  before  the  anterior  chamber  is  in- 
cised, but,  owing  to  the  greater  difficulty  of  extracting  the 
cataract  through  an  upper  incision,  iridectomy  is  absolutely 
indispensable.  If  it  is  desired  to  retain  the  circular  form 
of  the  pupil,  it  is  better  to  extract  from  below.  In  order 
to  avoid,  as  much  as  possible,  hemorrhage  from  the  flap 
into  the  anterior  chamber  during  the  operation,  adrenalin 
is  first  instilled  into  the  eye. 

6.  AVenzel's  operation  is  a  very  good  procedure  when 
the  iris  is  adherent  to  the  cataract  (Cataracta  accreta),  with 
or  without  inflammatory  exudate  formation  behind  the 
iris,  and  when  there  is  anterior  dislocation  of  the  lens 
from  glaucomatous  increase  of  the  intra-ocular  tension, 
provided  the  other  necessary  conditions  for  operation  are 


154  OPERATIONS  ON  THE  EYE. 

Fig.  47. — A  sickle-shaped  cystotome  and  Daviel's  scoop. 

Fig.  48. — Bowman's  scoop,  rough  at  the  point;  and  Critchett's, 
slightly  bent  over  at  the  end,  seen  from  the  side. 

Fig.  49. — The  same  instrument,  front  view. 

Fig.  50. — Waldau's  scoop. 

Fig.  51. — Pagenstecher's  scoop. 

Fig.  52. — Weber's  scoop. 

The  scoops  shown  in  Figs.  48-51  are  made  of  German  silver;  Weber's 
scoop  is  made  of  tortoise-shell. 

present.  The  cataract  knife  is  inserted  not  only  through 
the  cornea  but  also  through  the  iris,  and  carried  behind 
the  curtain  ;  it  is  then  brought  out  again  through  the  iris 
and  the  cornea,  the  blade  at  the  same  time  cutting  the  cat- 
aract, so  that  a  curved  incision  is  also  made  in  the  cap- 
sule, as  the  incision  is  completed  in  the  usual  way,  either 
upward  or  downward.  The  iris  is  then  excised  as  well  as 
possible,  just  as  in  the  case  of  an  optical  iridectomy.  If 
the  pupil  is  densely  adherent,  and  a  mass  of  exudate  is 
also  present  behind  the  iris,  it  will  be  impossible  to  draw 
the  membrane  out  of  the  anterior  chamber,  and  the  scis- 
sors will  have  to  be  introduced  into  the  chamber.  Weck- 
er's  scissors  are  useful  for  this  purpose  (Fig.  53).  The 
cataract  usually  escapes  without  any  difficulty. 

Accidents  and  Mistakes  in  the  Operation  for  Cataract. 

1.  When  the  conjunctiva  is  so  friable  in  old  persons 
that  the  tissue  tears  through  every  time  it  is  seized  with 
fixation-forceps,  Pamard's  spear  (Fig.  19)  or  Schweigger's 
fixation-forceps  may  be  used  for  steadying  the  globe. 

2.  In  old  persons  with  rigid  sclera,  especially  when 
much  cocain  has  been  instilled,  blood  or  air,  or  both,  may 
enter  the  anterior  chamber  immediately  after  the  incision 
(see  p.  70).  In  itself  this  accident  is  of  no  great  im- 
portance ;  but  the  blood  may  interfere  with  opening  the 
anterior  capsule,  while  a  bubble  of  air,  on  the  other  hand, 
if  anything,  makes  the  opening  of  the  capsule  more  dis- 
tinct. 

In  this  class  of  patients  the  delivery  of  the  lens  requires 


47 


48 


f 


49 


§      § 


50 


51 


52 


155 


156  OPERATIONS  ON  THE  EYE. 

somewhat  heavier  pressure  with  the  glass  spatula  or  the 
spoon  because  intra-ocular  tension  is  so  low.  After  the 
lens  has  been  delivered,  the  marked  negative  pressure, 
brought  about  by  the  diminution  in  the  contents  of  the 
globe,  causes  depression  of  the  cornea,  which  often  forms 
a  deep  pit ;  but  although  it  looks  queer  it  is  not  followed 
by  any  bad  consequences  except  that  in  such  cases  cata- 
ractous  matter  that  has  remained  behind  can  not  be  stripped 
out,  and  must  be  allowed  to  stay  or  be  flushed  out.  In 
these  cases  the  first  bandage  must  be  applied  somewhat 
more  loosely,  so  as  to  allow  the  aqueous  humor  to  collect 
again  and  bring  the  cornea  back  to  its  original  position. 

3.  Several  mistakes  are  possible  in  making  the  corneal 
incision.  In  the  first  place  the  knife  may  be  held  with 
the  edge  directed  downward  instead  of  upwTard  as  it  is 
carried  through  the  anterior  chamber.  If  such  a  mistake 
has  been  made  it  is  best  to  withdraw  it  rapidly,  if  possible 
without  allowing  the  aqueous  humor  to  escape,  and  reinsert 
it  in  the  proper  way  through  the  first  wound  if  possible, 
if  not,  alongside  of  it.  In  the  second  place  the  knife  may 
be  wielded  with  an  excited  and  trembling:  hand  as  the  in- 
cision  is  made,  which  is  apt  to  cause  premature  escape  of 
the  aqueous  humor  and  allow  the  iris  to  get  in  front  of  the 
knife.  It  is  best  under  such  circumstances  to  continue 
the  incision  quietly,  cutting  the  iris  at  the  same  time, 
although,  of  course,  the  resulting  iridectomy  will  be  irreg- 
ular or  too  small.  That,  however,  can  be  remedied  after- 
ward with  forceps  and  scissors. 

A  third  and  more  serious  mistake  is  to  make  the 
incision  too  small,  especially  when  the  nucleus  is  large. 
The  incision  in  that  case  must  be  cautiously  enlarged 
either  with  Desmarres'  blunt-pointed  knife  (Fig.  36)  or 
Wecker's  (Fig.  53)  or  Stevens'  scissors  (Fig.  92).  If  a 
hard  nucleus  sticks  fast  in  the  wound  it  can  be  rolled  out 
with  a  Gräfe's  cystotome  by  hooking  it  into  the  side  of 
the  nucleus  along  the  equator. 

4.  If  the  patient  bears  down  while  the  incision  is  being 
made,  the  aqueous  humor  is  rapidly  forced  into  the  wound 


ACCIDENTS  IN   OPERATION  FOR   CATARACT.    157 

and  brings  the  iris  with  it.  In  such  a  case  the  prolapsed 
portion  of  the  iris  is  seized  transversely — that  is,  in  a  line 
parallel  to  the  corneal  margin,  gentle  pressure  being  made 
on  the  iris  while  the  iridectomy  is  being  performed. 

5.  If,  owing  to  abnornal  toughness  or  thickening,  the 
opening  in  the  capsule  turns  out  too  small  or  can  not  be 
effected  at  all,  which  may  also  be  due  in  part  to  a  dull 
cystotome  or  interference  with  its  action  by  blood  getting 
into  the  anterior  chamber  and  obscuring  the  held,  the 
operator  must  carefully  guard  against  trying  to  force  the 
delivery  by  excessive  pressure,  as  that  would  result  in 
escape  of  the  vitreous  instead  of  the  cataract.  The  thing 
to  do  is  to  take  a  cystotome  and  improve  the  opening.  If 
the  wound  gapes  during  the  attempt  to  deliver  the  lens, 
without  any  part  of  the  cataract  being  seen,  it  should  at 
once  suggest  that  the  capsule  may  not  have  been  properly 
opened. 

6.  A  more  serious  accident  is  failure  of  the  nucleus  to 
present  in  the  wound,  with  the  tendency  to  glide  toward 
the  upper  ciliary  body,  an  accident  which  has  already 
been  referred  to  for  the  purpose  of  illustrating  the  great 
importance  of  good  illumination  in  cataract  operation. 
As  soon  as  it  is  noticed  that  the  upper  border  of  the 
nucleus  fails  to  present  in  the  wound,  although  cortical 
matter  has  escaped,  this  possibility  must  at  once  be  thought 
of  and  lead  to  a  careful  examination  of  the  state  of  affairs. 
This  requires  a  very  good  light.  With  a  cystotome  the 
nucleus,  if  it  has  moved  too  far  upward,  may  be  pushed 
down  again  until  the  upper  border  is  behind  the  wound, 
when  quick,  firm  pressure  on  the  lower  border  of  the 
cornea  will  cause  it  to  present  in  the  wound. 

7.  A  very  grave  and  very  important  accident  is  pro- 
lapse of  the  vitreous.  It  should,  by  all  means,  be  avoided, 
for  it  may  have  evil  consequences  not  only  immediately 
after  the  operation,  in  the  form  of  opacities  in  the  vitreous, 
infection  of  the  vitreous  and  retinal  detachment,  but  also 
at  some  later  period.  When  there  is  myopia  especially, 
retinal  detachments   may  develop  and  end   in  blindness. 


158  OPERATIONS  ON  THE  EYE. 

As  a  rule,  prolapse  of  the  vitreous  injures  the  shape  of 
the  pupil,  because  it  is  impossible  to  replace  the  iris  which 
has  been  forced  into  the  wound.  This  gives  rise  to  the 
disadvantages  which  have  been  discussed  on  p.  141. 
As  a  normal  vitreous  body,  after  prolapse,  remains  some 
time  in  the  cataract  wound,  closure  is  delayed  by  from  one 
to  two  weeks,  and  during  all  this  time  infection  of  the 
interior  of  the  eye  is  possible.  Fortunately  every  loss  of 
vitreous  is  not  followed  by  loss  of  eyesight  or  of  the  eye, 
especially  when  only  the  anterior  portion  of  the  vitreous, 
which  occasionally  is  partially  liquefied  in  cataractous 
eyes,  escapes  at  -the  operation ;  but  it  should  be  an  in- 
violable principle  with  an  ophthalmic  surgeon  to  leave 
the  vitreous  unhurt  and  untouched,  whether  the  operation 
is  performed  for  cataract  or  for  any  other  purpose. 

The  appearance  of  the  eye  after  an  escape  of  vitreous 
at  an  operation  for  cataract  differs  according  as  the  vitreous 
is  normal  or  liquefied.  In  the  former  case  it  may  be  so 
watery  as  to  be  barely  distiguishable  from  aqueous  humor. 
Unless  the  operator  is  careful,  a  large  quantity  may  escape 
during  the  operation,  leaving  the  globe  collapsed.  This 
is,  therefore,  an  important  caution  in  the  case  of  eyes  in 
which  the  vitreous  is  probably  liquefied  (in  myopia  after 
iridochoroiditis).  Liquefaction  of  the  vitreous  is  recog- 
nized by  the  fact  that  it  can  be  drawn  out  in  threads. 
When  normal  vitreous  escapes  through  the  cataract  wound, 
the  edges  are  forced  apart  momentarily  by  the  escape  of  a 
large  transparent  prolapse  of  a  substance  resembling  fresh 
white  of  egg.  The  dark  cavity  of  the  interior  of  the 
eye  shines  through  most  uncannily  in  the  depths  of  the 
transparent  mass.  If  the  proper  thing  is  done  and  done 
at  once — that  is,  the  speculum  removed,  pressure  on  the 
eye  diminished,  and  the  patient  quieted  down — it  may 
occasionally  be  possible  to  prevent  the  escape  of  normal 
vitreous  after  it  has  entered  the  wound.  When  the  zonule 
is  torn,  however,  or  the  hyaloid  membrane  has  been  split, 
it  is  the  rule  for  a  variable  quantity  to  escape  from  the 
wound. 


ACCIDENTS  IN  OPERATION  FOR  CATARACT    159 

Prolapse  of  the  vitreous  may  be  favored  or  caused 
by  some  morbid  condition  of  the  eye  or,  rather,  of  the 
zonule,  which  may  be  atrophied  or  partially  lacerated  and 
therefore  fail  to  prevent  the  escape  of  the  vitreous.  Ab- 
normality of  the  zonule  is  specially  apt  to  be  present  in 
extreme  myopia,  in  over-ripe  cataract,  and  after  chronic 
uveitis  and  other  varieties  of  degeneration  of  the  vitreous. 
Sometimes  the  watery  nature  of  the  vitreous  betrays  itself 
before  the  operation  by  tremor  of  the  lens  during  rapid 
movements  of  the  eye.  In  non-congenital  lateral  dislo- 
cation of  the  lens  and  in  pure  luxation  of  the  lens  pro- 
lapse of  the  vitreous  is  almost  unavoidable  at  the  opera- 
tion. 

In  the  normal  eye  prolapse  of  the  vitreous  may  be 
brought  about  by  a  faulty  behavior  on  the  part  of  the 
patient.  At  the  slightest  sensation  of  pain,  and  sometimes 
even  when  there  is  no  pain,  some  patients  compress  the 
eye  so  that  the  contraction  of  the  external  muscles  and  of 
the  lids  forces  the  vitreous  into  the  wound,  even  when  the 
operation  is  faultlessly  carried  out. 

Finally,  a  number  of  errors  that  are  apt  to  be  com- 
mitted at  the  operation  are  capable  of  causing  this  unfor- 
tunate accident.  The  danger  of  excessive  pressure  with 
the  fixation-forceps  and  wounding  of  the  inner  angle  in 
this  respect  has  already  been  referred  to.  When  the 
opening  in  the  capsule  is  insufficient,  or  no  opening  at  all 
has  been  made,  forcible  manipulation  for  the  purpose  of 
expelling  the  lens  may  cause  the  vitreous  to  escape  even 
before  the  lens.  The  accident  most  frequently  occurs 
during  and  after  the  delivery  of  the  cataract,  while  remains 
of  the  same  or  even  some  portions  of  the  capsule  are  being 
removed.  When  this  is  attempted  with  the  forceps,  even 
though  it  be  with  the  greatest  caution,  prolapse  of  the 
vitreous  almost  always  ensues,  hence  the  operator  should 
never  yield  to  the  temptation  of  resorting  to  this  pro- 
cedure when  he  finds  thickened  pieces  of  capsule  with  or 
without  adhering  cortical  matter.  In  regard  to  cataractous 
remains  in  general,  the  rule  to  expel  and  express  only 


160  OPERATIONS  ON  THE  EYE. 

what  comes  away  readily  and  without  too  great  expendi- 
ture of  force  should  never  be  transgressed,  nor  should  it 
he  forgotten  that  the  introduction  of  an  instrument  into 
the  anterior  chamber  after  the  delivery  of  the  cataract  is 
always  apt  to  be  followed  by  injury  and  escape  of  the 
vitreous. 

The  earlier  the  prolapse  of  the  vitreous  takes  place 
during  the  operation,  the  more  complicated  will  be  the 
situation  and  the  more  difficult  will  it  be  to  finish  the 
operation.  If  it  appears  immediately  after  incision  of  the 
globe,  the  iris,  which  has  usually  been  carried  into  the 
wound,  must  at  once  be  trimmed  off  with  the  scissors  and 
a  snare  (wire  loop)  introduced  to  bring  out  the  cataract, 
Avhich  otherwise  sinks  into  the  depths  of  the  eye.  During 
this  procedure,  which  must  be  carried  out  as  rapidly  as 
possible,  pressure  on  the  bulb  with  the  instrument  or 
speculum  must  be  avoided  with  the  greatest  care.  The 
snare  (Fig.  31)  must  be  broad  enough  to  take  a  firm  hold 
of  the  cataract.  It  is  introduced  vertically  around  the 
upper  edge  of  the  cataract  and  the  handle  is  depressed  so 
as  to  seize  the  cataract  from  behind  ;  the  instrument  is 
then  carefully  withdrawn,  forcing  the  cataract  slightly 
against  the  iris  and  cornea  to  prevent  its  escaping  laterally 
from  the  loop.  As  soon  as  the  cataract  has  been  ex- 
tracted the  patient  is  told  to  close  his  eyes,  and  the  bandage 
is  applied.  It  is  usually  impossible  to  replace  the  iris, 
nor  is  the  attempt  to  do  so  advisable,  because  it  would 
only  be  attended  by  further  escape  of  the  vitreous.  If 
the  cataract  sinks  farther  into  the  depths  of  the  vitreous, 
and  can  not  be  removed  with  the  snare,  the  operation 
should  be  suspended,  the  bandage  applied,  and  the  patient 
let  alone  until  the  next  day,  when  there  is  a  possibility  of 
finding  the  cataract  at  its  proper  place  and  being  able  to 
remove  it  with  the  snare.  As  the  necessity  of  using  the 
snare  may  arise  at  any  cataract  operation  with  a  flap-incis- 
ion, it  is  always  well  to  have  the  instrument  ready  at  hand. 

Often  prolapse  of  the  vitreous  takes  place  because  the 
cataract  incision  is  too  small  and  it  requires  too  much  force 


ACCIDENTS  IN  OPERATION  FOR   CATARACT     161 

to  deliver  the  lens,  thus  endangering  the  integrity  of  the 
zonule. 

The  more  peripheral  the  incision — that  is,  the  farther 
away  from  the  edge  of  the  cornea — the  greater  will  be  the 
danger  of  prolapse  of  the  vitreous  when  other  favoring 
conditions  are  present.  Hence,  in  operating  on  an  eye  in 
which  prolapse  of  the  vitreous  is  to  be  feared,  the  incision 
should  lie  entirely  within  the  cornea. 

Sometimes  the  way  is  paved  for  the  escape  of  the  vitre- 
ous by  careless  manipulation,  causing  injury  to  the  zonule, 
especially  by  beginners  ;  either  excessive  pressure  upward 
may  be  made  in  applying  the  forceps  for  iridectomy,  or 
the  lens  may  be  drawn  from  side  to  side  and  severely 
pressed  upon  during  cystotomy.  [If  vitreous  escapes 
after  the  lens  has  been  extracted,  the  wound  should  be 
cleaned  of  protruding  vitreous  as  gently  and  rapidly  as 
possible  and  a  bandage  applied.  If  the  escape  of  vitreous 
has  been  great,  particularly  if  the  vitreous  is  thin  and 
there  is  a  tendency  for  the  eyeball  to  collapse,  a  tepid 
sterile  physiologic  salt  solution  should  be  injected  into  the 
vitreous  chamber  until  the  globe  assumes  its  proper  con- 
tour, as  has  been  recommended  (a  recommendation  which 
the  editor  can  heartily  endorse)  by  J.  A.  Andrews  and 
H.  Knapp. — Ed.] 

8.  The  gravest  complication  during  the  operation  is 
hemorrhage  from  the  choroid.  The  patient  feels  a  sudden 
agonizing  pain,  and  a  profuse  hemorrhage  takes  place  in 
the  deeper  layers  of  the  eye,  the  rush  of  blood  forcing  the 
vitreouV retina,  and  choroid  into  the  wound  and  partly 
through  it,  destroying  the  eye.  This  grave  accident  may 
not  appear  until  after  the  operation,  when  it  is  recognized 
by  the  occurrence  of  severe  pain  and  saturation  of  the 
dressings  with  blood.  Immediate  enucleation  is  the  best 
plan  in  such  cases. 

[An   attempt    may   be   made    to    stop  the  hemorrhage 
without  resort  to  enucleation  :  upright  position,  hypoder- 
mics of  morphin,  and  full,  firmly  applied  antiseptic  dress- 
ing.— Ed.] 
11 


162  OPERATIONS  ON  THE  EYE. 

The  best  safeguards  against  the  occurrence  of  a  fatal 
hemorrhage  of  this  kind  are  perfect  rest  after  the  opera- 
tion, and,  in  the  case  of  arteriosclerotic  patients,  measures 
to  guard  against  sudden  changes  of  pressure  in  the  vascular 
system  of  the  head  and  eye;  as  by  cough  and  the  like. 
Finally,  in  making  the  cataract  incision  the  operator  must 
be  careful  to  cut  slowly  in  order  not  to  diminish  the  intra- 
ocular pressure  too  rapidly,  and  thus  cause  rupture  of  the 
vessels  in  the  interior  of  the  eye. 

Method  of  Applying  Dressing  and  After-treatment. 

Whatever  dressing  may  be  used,  and  whether  the  eye  is 
bandaged  or  not,  the  chief  object  under  all  circumstances 
is  to  induce  as  rapid  union  of  the  wound  as  possible, 
because  it  is  the  strongest  precaution  against  secondary 
infection.  Most  ophthalmologists  at  the  present  time  keep 
the  operated  eye  bandaged  at  least  for  several  days,  and 
have  the  bandage  changed  every  twenty-four  hours.  It 
is  my  custom  to  keep  both  eyes  bandaged  for  twenty-four 
hours,  changing  the  dressing  once  or  twice,  then  to  keep 
the  operated  eye  bandaged  day  and  night  for  from  three 
to  six  days,  and  at  night  only  for  two  weeks  longer.  For 
restless  patients  who,  especially  at  night,  are  apt  to  injure 
the  eye  by  rubbing  or  striking  against  it,  Snellen's  alumi- 
num disc  should  be  incorporated  in  the  dressing,  or  a 
screen  should  be  applied. 

If  no  bandage  is  to  be  used  the  eye  must  at  least  be 
protected  by  a  screen. 

Twenty-four  hours  after  the  operation  the  eye  should  be 
examined ;  but  in  most  cases  inspection  of  the  lower  part 
of  the  cornea  and  the  anterior  chamber  is  sufficient,  the 
wound  remaining  covered  by  the  upper  lid. 

After  an  experience  of  many  years  H.  Pagenstecher 
again  recommends  von  Hoffmann's  ichthyol  dressing,  and 
the  excellent  results  he  has  obtained  with  that  procedure 
speak  strongly  in  its  favor. 

Pure  ichthyol  (from  the  Ichthyol  Company,  Cordes, 
Hermanni  &  Co.,  Hamburg)  is  spread  on  a  piece  of  gauze 


ACCIDENTS  INTERFERING    WITH  HEALING.     163 

saturated  with  liquid  paraffin,  and  laid  on  the  eye.  Both 
eyes  are  then  covered  with  cotton,  which  is  held  in  place 
by  wire-screen  spectacles  to  protect  the  eyes  against  injury. 
On  the  second,  third,  or  fourth  day  the  ichthyol  dressing 
is  removed  from  the  eye  that  has  been  operated  upon  and 
only  applied  at  night ;  this  is  kept  up  for  several  nights. 

This  dressing,  with  which  I  have  also  had  practical 
experience  for  a  year,  and  which  I  find  very  useful,  is  also 
justified  on  theoretic  grounds.  It  has  already  been  stated 
(p.  58)  that  the  edges  of  the  lids  are  most  liable  to 
cause  infection,  and  should  therefore  be  cleansed  as  scrup- 
ulously as  possible.  Both  the  ichthyol  and  the  paraffin 
at  least  have  the  property  of  mechanically  preventing  any 
microbes  that  may  happen  to  be  on  the  edges  of  the  lids 
from  escaping  into  the  conjunctival  sac.  It  is  also  prob- 
able that  the  ichthyol  has  some  disinfecting  action. 

Rest  in  bed  should  be  insisted  upon  for  at  least  twenty- 
four  hours,  and  in  most  cases  for  several  days,  especially 
when  the  operation  has  been  performed  without  iridectomy. 
In  the  latter  case  complete  rest  on  the  part  of  the  patient 
is  particularly  necessary,  and  the  eye  must  be  protected 
against  a  blow  or  rubbing  during  the  night ;  Knapp  there- 
fore advises  that  these  patients  should  have  their  arms 
tied.  To  avoid  chewing  movements  the  diet  should  be 
liquid  for  the  first  three  days.  If  iridectomy  has  been 
performed,  however,  the  patient  may,  after  the  third  day, 
spend  the  greater  part  of  the  day  out  of  bed.  The  rule 
should  be  that  the  older  the  patient  the  shorter  should  be 
the  period  of  confinement  in  bed,  because  otherwise  the 
digestion  suffers,  with  resultant  loss  of  strength. 

It  is  not  advisable  to  discharge  a  patient  who  has  been 
operated  upon  for  cataract  before  the  sixteenth  day  (see 
p.  44). 

Accidents  Interfering  with  the  Healing  of  the  Wound  after 
Operations  for  Cataract. 

Delayed  closure  of  the  wound  and  failure  of  the  an- 
terior chamber  to  regain  its  normal  condition  for  several 


164  OPERATIONS  ON  THE  EYE. 

days  calls  for  careful  bandaging  of  the  eye  without  undue 
pressure,  or  simply  the  use  of  the  screen.  Delayed  closure 
is  observed  chiefly  in  weak,  ill-nourished  and  decrepit 
patients. 

Iritis  and  iridocyclitis  as  sequels  after  an  operation  for 
cataract  are  less  frequent  than  during  the  pre-anesthetic 
period.  These  conditions  not  only  delay  recovery  and 
keep  up  the  redness  and  irritation  of  the  eye  an  abnor- 
mally long  time,  but  may  be  the  cause  of  true  secondary 
cataract — that  is,  a  more  or  less  robust  membrane  in  the 
pupillary  region,  formed  by  the  posterior  capsule,  the  re- 
mains of  the  anterior  capsule,  and  inflammatory  iritic 
exudate.  Severe  iritis  may  lead  to  the  formation  of  a 
dense  "  plate,"  everywhere  adherent  to  the  pupillary 
margin. 

An  unpleasant  complication  is  slow  iridocyclitis  with 
punctate  deposits.  Sometimes  the  latter  are  few  in  num- 
ber; but  when  an  eye  that  has  been  operated  upon  for 
cataract  continues  to  present  ciliary  redness  for  more  than 
three  weeks,  such  deposits  are  usually  found  when  the  eye 
is  carefully  examined  with  a  lens.  The  inflammation  may 
last  weeks  and  months,  bringing  with  it  the  danger  of 
sympathetic  disease  of  the  other  eye.  It  probably  de- 
pends on  some  form  of  infection,  the  exact  nature  of 
which  is  as  yet  unknown  (see  p.  66). 

It  requires  careful  supervision,  atropin,  great  rest  for 
the  eyes  and  a  subdued  light,  and  if  it  fails  to  disappear 
under  such  treatment,  and  the  introduction  of  an  iodoform 
pencil  into  the  anterior  chamber  also  fails  to  bring  about 
recovery,  as  I  have  often  seen  it  do,  enucleation  is  indi- 
cated. 

[Dionin,  in  1  to  5  per  cent,  solution,  combined  with 
atropin,  is  of  great  service  in  postoperative  iritis.  In- 
ternally, salicylates,  in  full  doses,  are  useful,  and,  if  the 
patient's  constitution  can  bear  it,  diaphoretic  doses  of 
hydrochlorate  of  pilocarpin  (gr.  -|-  to  \).  Subconjunctival 
injections  of  saline  solution  and  of  cyanid  of  mercury  are 
also  to  be  considered. — Ed.] 


ACCIDENTS  INTERFERING    WITH  HEALING.     165 

Such  patients,  with  slightly  reddened  eyes,  deposits  on 
the  posterior  wall  of  the  cornea,  and  a  tendency  to  lacri- 
mation,  are  just  the  ones  who  are  apt  to  return  with  sym- 
pathetic disease  of  the  other  eye,  if  the  surgeon  yields  to 
their  importunities  and  allows  them  to  go  home  before  the 
eye  has  become  completely  quiescent  and  white.  Sym- 
pathetic disease  after  operation  for  cataract  has  also  become 
less  frequent  during  recent  decades ;  but  whenever  the 
operation  causes  cyclitis,  especially  if  the  wound  extends 
into  the  scleral  border,  the  possibility  of  that  horrible  dis- 
ease attacking  the  other  eye  must  be  borne  in  mind. 

Purulent  infection  of  the  eye  during  and  after  the 
operation  for  cataract  is  a  very  grave  complication  and,  as 
a  rule,  very  difficult  to  combat  successfully.  It  may  lead 
to  purulent  infiltration  of  the  edges  of  the  wound  and 
diffuse  cloudy  discoloration  of  the  cornea  within  twenty- 
four  hours  after  the  operation  and,  as  a  rule,  goes  on  irre- 
sistibly to  total  purulent  infiltration  and  breaking  down 
of  the  cornea,  with  more  or  less  inflammatory  edema  of 
the  bulbar  conjunctiva.  Often  the  inflammation  spreads 
rapidly  into  the  deeper  layers  and  causes  protrusion  of  the 
globe  and  ultimately  panophthalmia. 

A  purulent  infection  may  develop  after  the  first  day 
and,  in  fact,  at  any  time  until  the  wound  is  firmly  closed ; 
but  it  is  most  to  be  feared  on  the  first  and  second  days. 
As  it  is  usually  heralded  by  pain,  it  is  absolutely  necessary 
to  examine  the  eye  at  once  if  the  patient  complains,  as 
the  process  may  possibly  be  arrested  or  at  least  kept  within 
^~ bounds  if  discovered  at  the  very  beginning.  The  eye 
must  then  be  disinfected  in  the  manner  previously  de- 
scribed (see  p.  68). 

A  harmless  accident  after  an  operation  for  cataract  is  the  draining 
of  the  aqueous  humor  underneath  the  choroid  after  the  wound  has 
healed  and  the  anterior  chamber  has  been  restored.  The  latter  sud- 
denly becomes  shallow,  and  when  the  interior  of  the  eye  is  examined, 
the  choroid  is  discovered  as  a  tumor-like  prominence  of  grayish  or  gray- 
ish-brown color,  protruding  into  the  aqueous  and  forming  a  pseudotumor, 
which,  however,  need  not  alarm  the  surgeon.  Fuchs  has  observed  a 
comparatively  large  number  of  cases  in  which   the   aqueous   humor 


166  OPERATIONS  ON  THE  EYE. 

Plate  4. 

Operation  for  secondary  cataract,  after  Bowman,  with  two  needles. 

escaped  in  this  way  without  producing  any  harm.  The  fluid  makes  its 
way  through  a  tear  in  the  root  of  the  iris. 

Glaucoma  is  a  most  unpleasant,  although,  fortunately,  not  very  fre- 
quent, complication  after  operations  for  cataract.  Since  we  know,  that 
when  the  cataract  wound  is  slow  to  close  the  epithelium  of  the  cornea 
and  of  the  conjunctiva  may  proliferate  into  the  anterior  chamber  and 
form  a  complete  lining  for  it  as  well  as  for  the  iris  and  the  angles  of 
the  chamber,  we  understand  why  glaucoma  after  the  operation  for 
cataract  sometimes  defies  every  form  of  treatment. 

Occasionally  something  else  besides  iritis  and  deposits  on  the  cornea 
is  the  cause  of  protracted  reddening  and  irritation  of  the  eye ;  it  may 
be  a  capillary  fistula  in  the  scar  of  the  wound.  This  also  is  usually 
due  to  delayed  healing  of  the  wound,  the  epithelium  in  places  bridging 
over  the  wound-edges  and  thus  making  it  possible  for  a  small  fistula  of 
the  anterior  chamber  to  develop.  The  eye  under  such  circumstances 
often  frightens  a  surgeon,  because  of  the  minus  pressure  which  suggests 
a  cyclitis.  On  examining  the  scar  and  at  the  same  time  exerting  a 
gentle  pressure  on  the  eye,  a  little  fluid  will  be  seen  to  work  out  at  a 
certain  spot.  As  a  rule  cauterization  with  the  galvanocautery  is 
speedily  followed  by  recovery. 

Operation  for  Secondary  Cataract. 

Since  the  introduction  of  modern  methods  of  treating 
wounds,  this  operation,  which  was  formerly  a  much- 
dreaded  one,  in  spite  of  its  apparently  trifling  character, 
is,  when  properly  performed,  practically  harmless  and  at 
the  same  time  a  most  satisfactory  procedure.  In  many 
cases  vision  is  not  permanently  restored  until  it  has  been 
performed.  Its  object  is  to  perforate  the  membrane  which 
remains  behind  in  the  pupillary  region  after  a  cataract 
operation,  or  makes  its  appearance  later,  becomes  thick- 
ened and  interferes  with  vision,  so  that  the  center  of  the 
pupil  finally  is  freed  of  everything  capable  of  obstructing 
the  light.  Even  the  posterior  capsule  alone,  if  it  forms 
wrinkles  or  possesses  or  develops  areas  of  thickening,  may 
prove  a  serious  obstacle  to  vision,  and,  if  to  this  are  super- 
added remains  of  the  anterior  capsule,  epithelial  prolifera- 
tions of  the  latter,  causing  still  further  thickening,  and 
remains  of  cortical  material,  the  result  is  often  a  con- 
tinuous, thin,  grayish  membrane,  which  may  easily  reduce 


OPERATION  FOR  SECONDARY  CATARACT.       167 

vision  to  \  or  \,  even  when  there  is  no  inflammation  in 
the  case.  If  the  operation  is  followed  by  iritis,  the  sec- 
ondary cataract  may  be  even  thicker. 

In  myopic  individuals  more  or  less  secondary  cataract 
is  the  rule. 

The  persistence  of  large  remains  of  cortical  matter  does 
not  always  produce  a  secondary  cataract.  A  very  clear 
pupil  may  be  formed  in  spite  of  them,  even  though  it  takes 
some  time,  provided  only  there  is  no  inflammation.  This 
is  probably  explained  by  the  fact  that  the  cortical  remains 
keep  the  anterior  capsule  and  its  proliferating  capsular 
cells  away  from  the  posterior  capsule  for  some  time  and 
hold  the  edges  of  the  tear  in  the  anterior  chamber  apart, 
so  that  the  capsular  cells  are  unable  to  form  deposits  on 
the  posterior  capsule,  and  after  the  remains  have  been 
absorbed  the  posterior  capsule  remains  perfectly  clean. 

The  indication  for  discission  of  a  secondary  cataract  or 
of  a  wrrinkled  posterior  capsule  depends  on  the  accuracy 
of  vision  that  is  necessary  in  any  individual  case.  If  the 
patient's  work  is  such  as  to  require  accurate  vision,  a  sec- 
ondary one  will  be  necessary,  even  if  he  has  a  visual 
acuity  of  one-half. 

When  a  cataract  operation  is  followed  by  a  normal  re- 
covery, the  one  for  secondary  cataract  may  be  undertaken 
as  early  as  two  or  three  weeks  later.  It  is  better  to  avoid 
delay,  because  even  a  thin  secondary  membrane  becomes 
more  rigid  and  harder  with  time.  It  is  therefore  easier  to 
divide  them  early,  especially  if  the  finest  portion  of  the 
membrane  is  selected  for  discission.  However,  the  eye 
ought  to  have  lost  every  sign  of  redness  before  it  is  at- 
tempted, and  the  general  rule  wdiich  has  been  given  above, 
that  inflamed  eyes  must  not  be  operated  upon,  applies 
particularly  to  these  cases,  barring  only  the  exceptions 
noted  on  p.  68. 

Discission  of  a  secondary  cataract  can  be  performed 
equally  well  four  to  eight  wreeks  after  the  primary  one. 

In  this  operation  it  is  always  to  be  remembered  that  it 
is  free  from  danger  only  when  strict  antiseptic  precautions 


168  OPERATIONS  ON  THE  EYE. 

Figs.  53-59. — Instruments  for  secondary  cataract  operation. 
Fig.  53. — von  Wecker' s  scissors-forceps. 
Fig.  54. — Desmarres'  capsule- forceps. 
Fig.  55. — Desmarres'  capsule-forceps,  modified  by  Liier. 
Fig.  56. — Bowman's  discission-needle. 
Fig.  57. — Knapp' s  capsule-knife. 
Fig.  58. — Knapp' s  capsule-knife. 
Fig.  59. — Weiss'  cataract  needle  with  one  cutting  edge. 

are  observed.  Formerly  it  was  almost  as  dangerous  as 
the  cataract  operation  itself.  Surgeons  did  not  like  to 
resort  to  it  because  it  was  also  apt  to  be  followed  by  severe 
purulent  inflammation  and  sympathetic  disease  of  the  other 
eye.  In  fact,  a  case  was  reported  recently  in  which,  in  spite 
of  modern  antiseptic  precautions — although  it  was  in  a  walk- 
ing patient — the  eye  was  lost  through  panophthalmia. 

It  follows,  therefore,  that  the  eye  must  be  prepared 
quite  as  carefully  for  a  secondary,  as  for  a  primary  cataract 
operation.  It  is  also  advisable,  before  entering  the  ante- 
rior chamber,  to  flood  the  operative  field  with  a  1  :  5000 
solution  of  bichlorid  of  mercury,  so  that  the  needle  or 
needling  knife  makes  its  way  through  a  thin  layer  of  the 
antiseptic  fluid.  It  is  also  important  not  to  touch  anything 
with  the  needle  first  (Fig.  1). 

The  small  puncture  will  heal  more  quickly  if  it  is  placed 
under  the  conjunctiva,  at  the  scleral  border,  after  the  method 
of  Kuhnt,  because  it  is  in  a  vascular  tissue  and  there  is  less 
danger  of  the  wound  filling  with  vitreous.  A  prolapse  of 
the  vitreous  into  the  wound  may  also  take  place  in  this 
operation  if  the  wound  is  in  the  cornea,  even  though  it  be 
a  small  one.  For  the  vitreous  material  protrudes  through 
the  wound  like  thread,  at  first  clear,  and  later  of  a  grayish 
color,  and  endangers  and  interferes  with  recovery.  It 
forms  a  bridge  by  which  infection  may  reach  the  interior 
of  the  eye.  At  the  best  it  delays  healing  and  annoys  the 
patient  by  the  irritation  that  is  set  up.  Sometimes  these 
threads  consist  merely  of  the  so-called  filamentous  keratitis, 
a  less  dangerous  but  equally  tedious  complication.  A  poor 
needle — as,  for  example,  one  of  the  wrong  width  (see  Fig. 


11 


56 


59 


57  58 


169 


170  OPERATIONS  ON  THE  EYE. 

6,  b) — favors  the  occurrence  of  prolapse  of  the  vitreous. 
Needles  that  have  been  ground  too  often,  and  have  there- 
fore become  too  narrow  at  the  cutting  edge,  also  predispose 
to  this  accident,  because,  as  the  needle  advances,  the  handle 
also  pushes  the  wound  edges  apart  and  makes  a  roundish 
hole,  which  is  slow  to  close  and  sometimes  permits  the 
vitreous  to  escape.  Needling  knives  that  are  not  of  the 
proper  construction  may  produce  similar  results. 

Instruments  suitable  for  this  purpose  are  sharp  discission 
needles  of  various  shapes  (Figs.  41,  43,  56),  or  needling 
knives  as  designed  by  Knapp  (Figs.  57,  58)  and  Kuhnt 
(like  Knapp's  instruments,  but  bent  over). 

With  good  instruments  of  this  kind  it  is  also  possible 
to  enter  the  cornea  (Knapp)  and  in  that  way  attain  more 
freedom  of  movement  with  the  instrument. 

The  steps  of  the  operation  depend  on  the  kind  of  sec- 
ondary cataract  present.  First  of  all,  the  eye  must  be 
carefully  examined  under  good  lateral  illumination  with 
the  magnifying  lens  to  determine  the  nature  of  the  cata- 
ract and  the  location  of  the  blackest,  that  is,  the  thinnest, 
spots.  The  spots  which  lie  nearest  the  center  of  the  pupil 
are  first  utilized  for  making  the  opening. 

A  bright  light  is  indispensable  for  the  proper  perform- 
ance of  a  secondary  cataract  operation ;  electric  light  is  the 
best. 

The  eye,  having  been  dilated  with  atropin  and  cocain- 
ized and  the  speculum  introduced,  the  globe  is  seized  with 
the  fixation-forceps  opposite  the  point  where  the  needle  or 
knife  is  to  be  introduced  at  the  scleral  border.  This  spot 
is  chosen  where  the  introduction  of  the  blade  will  most 
easily  enable  the  operator  to  make  a  free  incision  in  the 
membrane  with  the  first  movement  of  his  hand,  as  indi- 
cated by  the  arrow  in  Fig.  3.  The  needle  or  knife  is 
introduced  at  a  point  2  to  3  mm.  from  the  corneal  border, 
through  the  conjunctiva  and  sclera,  into  the  anterior  cham- 
ber, so  that  the  instrument  enters  just  in  front  of  the  iris, 
and  is  introduced  along  the  iris  until  the  desired  thin  spot 
in  the  secondary  cataract  has  been  reached  (see  Plate  5). 


OPERATION  FOR  SECONDARY  CATARACT.       171 

After  the  first  incision  has  been  completed,  a  second  one 
is  made  vertically  or  obliquely  to  the  first,  either  by 
rotating  the  needle  or  knife  through  90°  around  its  long 
axis,  or  by  introducing  it  a  second  time  at  some  other  ap- 
propriate point  on  the  scleral  border.  It  is  better  not  to 
attempt  to  divide  thick  areas  and  threads  and  cords  in  a 
secondary  cataract,  because  the  attempt  is  usually  not  suc- 
cessful with  this  method.  The  instruments  should  never 
be  thrust  deep  into  the  vitreous  body.  No  aqueous  humor 
should  escape — an  accident  which  can  readily  be  avoided 
with  this  method  of  introducing  the  instrument  if  the 
needle  or  the  knife  has  a  good  point  and  a  good  edge. 

When  the  secondary  cataract  is  somewhat  thicker  and 
does  not  present  any  thin  areas,  the  capsule-knife  is  intro- 
duced more  nearly  at  a  right  angle — i.  e.,  through  the 
cornea  about  2  to  3  mm.  from  the  border ;  the  operation  is 
then  completed  in  a  similar  manner,  the  edge  of  the  knife 
being  brought  into  action  as  much  as  possible.  Or  the 
operation  may  be  performed  with  two  needles,  after  Bow- 
man, which  is  more  a  lacerating  than  a  cutting  procedure. 
According  to  my  experience  this  operation,  which,  until 
recently,  I  used  almost  exclusively,  or  at  least  in  a  large 
number  of  cases,  has  many  advantages  and,  if  properly 
performed,  is  quite  free  from  danger  to  the  eye.  Cor- 
rect technic  consists  in  introducing  the  two  needles  as 
shown  in  Plate  4,  one  after  the  other  or  at  the  same  time, 
at  a  point  about  2  taiLmm.  from  the  corneal  border  and  at 
directly  opposite  points,  and  bringing  them  out .  again 
through  the  secondary  cataract  at  the  same  point  in  the 
center  of  the  pupil.  By  separating  the  points  of  the 
needles  with  a  symmetrical  movement,  a  short  horizontal 
tear  is  effected  without  the  traction  being  communicated 
to  the  periphery ;  the  tear  is  then  increased  in  a  vertical 
direction  by  separating  the  points  of  the  needles  from  one 
another  from  above  dowmvard.  The  two  movements  may 
have  to  be  repeated  once  more  with  somewhat  larger  ex- 
cursions, and,  as  a  rule,  the  resulting  gap  is  then  large 
enough,  even  if  the  secondary  cataract  is  quite  thick  and 


172  OPERATIONS  ON  THE  EYE. 

rigid.  It  is  even  possible  with  the  needling  operation  to 
divide  any  small  cords  that  may  accidentally  be  found  at 
the  center  of  the  cataract.  This  is  done  by  crossing  the 
needles  slightly  as  they  are  introduced  into  the  membrane. 

When  a  thickened  portion  is  found  at  the  center  of  an  otherwise 
rather  thin  secondary  cataract,  it  can  be  removed  with  Desmarres'  spe- 
cially constructed  capsule-forceps  (Fig.  54)  or  with  Lüer's  modification 
of  the  instrument  (Fig.  55).  A  Gräfe  knife  or  some  other  narrow- 
bladed  knife  (Figs.  76  and  78)  is  introduced  through  the  cornea  or  even, 
if  there  is  an  appropriate  spot,  directly  through  the  secondary  cataract, 
which  is  then  seized  with  a  small  capsule-forceps.  The  instrument 
shown  in  Fig.  55  may  also  be  thrust  directly  through  both  the  cornea 
and  the  secondary  cataract.  The  method  is  somewhat  more  radical 
than  those  mentioned  above,  but  it  can  nevertheless  be  employed  with- 
out doing  any  injury  to  the  vitreous  or  causing  it  to  enter  the  corneal 
wound. 

When  the  secondary  cataract  consists  of  thick,  compli- 
cated masses  of  tissue  everywhere  adherent  to  the  pupil, 
or  when  there  has  been  complete  upward  displacement  of 
the  pupil  after  a  bad  recovery,  and  the  iris  is  usually  cov- 
ered on  the  posterior  aspect  with  a  membrane  consisting 
of  inflammatory  exudate  and  masses  of  secondary  cataract, 
it  is  often  a  very  difficult  task  to  make  an  opening  in  this 
diaphragm.  After  traumatic  cataract,  when  convalescence 
has  been  complicated  with  inflammation  and  after  com- 
plete distortion  of  the  pupil,  we  often  find  ourselves  in  the 
same  predicament. 

The  most  important  rule  is  not  to  operate  until  the  eye 
has  been  free  from  inflammation  for  from  six  months  to 
one  year,  as  otherwise  the  operative  wound  closes  again  in 
a  very  short  time. 

The  least  severe  operation  in  these  cases  consists  in  the 
following  procedure  :  Two  of  Bowman's  needles  are  intro- 
duced, one  after  the  other,  from  the  temporal  side,  through 
the  cornea  and  iris,  near  the  edge  of  the  former,  parallel 
to  each  other  and  3  mm.  apart,  and  the  two  needles  are 
then  advanced  almost  to  the  other  side  of  the  iris.  The 
needles  are  then  held  by  an  assistant,  who  at  the  same 
time  fixes  the  globe  with  the  forceps.  Their  purpose  is 
to  prevent  the  thickened  iris  from  slipping  backward  as 


OPERATION  FOR  SECONDARY  CATARACT.       173 

the  diaphragm  is  divided  between  the  two  needles.  To 
accomplish  this  a  Knapp's  capsule-knife  is  introduced 
opposite  the  points  where  the  needles  have  entered — that 
is  to  say,  near  the  nasal  edge  of  the  cornea  and  in  the 
horizontal  meridian,  introducing  it  into  the  anterior  cham- 
ber almost  as  far  as  the  point  of  entrance  of  the  two  needles. 
The  edge  is  then  directed  backward,  and  the  iris  divided 
as  completely  as  possible  between  the  needles.  As  a  rule, 
the  incision  becomes  sufficiently  stretched  by  the  prolapsing 
vitreous  body.  No  vitreous  is  lost  in  this  procedure  be- 
cause only  three  small  punctures  are  made. 

A  more  radical  operation,  because  combined  with  more 
or  less  escape  of  the  vitreous,  and  a  more  useful  one  for 
many  cases,  is  that  of  de  Wecker,  which  is  performed 
with  the  excellent  scissors-forceps  (Fig.  53)  designed  by 
him.  With  a  narrow  keratome  or  knife,  as  in  the  case  of 
linear  extraction,  access  to  the  iris  is  obtained,  and  at  the 
same  time  the  knife  is  also  introduced  into  the  thickened 
iris.  The  corneal  incision  should  only  be  large  enough  to 
permit  of  the  introduction  of  the  closed  scissors-forceps. 
The  scissors  are  then  opened  in  the  anterior  chamber ;  one 
of  the  blades  introduced  through  the  wound  and  placed 
behind  the  membrane  consisting  of  secondary  cataract  and 
iris,  while  the  other  blade  is  pushed  as  far  in  front  of  the 
iris  as  possible,  when  the  intervening  tissues  are  divided 
with  one  snip,  leaving  a  widely  gaping  cleft.  If  neces- 
sary, a  second  incision  carTbe  made  so  as  to  form  a  V-shaped 
wound.     The  remaining  tag  usually  retracts. 

A  variety  of  other  methods  have  been  recommended  for 
the  excision  of  pieces  from  the  center  of  an  iris  compli- 
cated by  thickenings  of  the  capsule,  but  the  loss  of  vitreous 
at  the  operation  is  sometimes  greater  than  is  quite  justi- 
fiable. Not  infrequently  the  loss  of  vitreous  is  too  great, 
even  with  the  small  incision  necessary  for  the  introduction 
of  Wecker' s  scissors. 

Dressing  and  after-treatment  must  be  as  scrupulously 
attended  to  after  an  operation  for  secondary  cataract  as 
after  a  primary  operation. 


174  OPERATIONS  ON  THE  EYE. 

Treatment  of  Operation  for  Senile  Cataract  by  Couching  and 
Depression. 

These  antiquated  methods,  which  were  practised  before 
cataract  extraction  came  into  vogue,  are  not  used  by  sci- 
entific physicians  except  in  very  rare  cases.  In  India,  on 
the  other  hand,  and  possibly  among  other  distant  peoples, 
the  method  is  still  practised  by  the  native  lay  doctors. 
For  reasons  referred  to  previously  (p.  118)  the  procedure 
ends  in  failure  in  40  per  cent,  of  the  cases.  It  might  pos- 
sibly be  indicated  when  the  vitreous  is  liquefied,  especially 
in  cases  of  marked  myopia  when  a  corneal  incision  would 
cause  the  escape  of  almost  all  of  the  vitreous,  which  would 
be  followed  by  a  retinal  detachment.  In  such  a  case 
couching,  with  scleroticonyxis — that  is,  puncture  through 
the  sclera — may  be  advisable,  as  the  operation  through  the 
cornea  (keratonyxis)  is  more  difficult  and  less  reliable. 
According  to  Scarpa's  method  the  operation  consists  in 
turning  the  cataract  over  backward  and  upward  with 
a  couching  needle  (resembling  the  needle  shown  in  Fig. 
41,  except  that  it  is  bent  on  the  flat).  The  eye  having 
been  prepared  in  the  same  way  as  for  a  cataract  operation, 
the  globe  is  seized  with  a  fixation-forceps,  immediately 
under  the  cornea,  and  steadied  while  the  needle  is  intro- 
duced into  the  sclera  3  to  4  mm.  from  the  corneal  margin 
and  slightly  underneath  the  horizontal  meridian,  as  though 
it  were  to  be  carried  toward  the  center  of  the  vitreous. 
The  edge  of  the  needle  should  lie  in  the  horizontal  plane, 
the  convex  surface  directed  upward.  After  the  needle 
has  penetrated  the  globe  to  a  distance  of  about  0.5  cm.,  it 
is  rotated  around  its  axis  until  the  convex  surface  is 
directed  forward.  The  point  is  now  directed  forward  and 
pushed  in  between  the  iris  and  the  lens.  After  it  has  en- 
tered the  pupil  as  far  as  the  pupillary  margin  of  the  oppo- 
site side,  the  shaft  of  the  needle  is  elevated  in  front,  thus 
imparting  a  lever-like  action  to  the  needle  and  depressing 
the  lens  downward  and  outward.  The  cataract  must  be 
maintained  for  a  few  moments  in  this  new  position  until 
it  becomes  completely  surrounded  by  the  vitreous,  after 


OPERATIVE  TREATMENT  OF  DISLOCATED  LEXS.     175 

which  the  needle  is  withdrawn  in  the  same  way  as  it  was 
introduced. 

The  cataract  may  rise  again  and  return  to  its  original 
position.  If  it  is  soft,  it  usually  breaks  up  without  being 
depressed.  As  a  rule  the  capsule  is  opened  in  this  pro- 
cedure. Sometimes  the  cataract  would  get  into  the  anterior 
chamber.  The  operation  is  not  such  a  very  simple  one. 
Depression — that  is,  pushing  the  cataract  directly  down- 
ward— is  still  less  to  be  recommended. 

The  Operative  Treatment  of  Dislocation  of  the  Lens. 

The  lens,  whether  clear  or  cloudy,  may  be  dislocated 
spontaneously,  especially  in  myopic  eyes  and  after  chronic 
iridochoroiditis,  or  as  a  result  of  traumatism — a  blow  or 
a  fall  and  the  like.  The  dislocation  takes  place  either  into 
the  vitreous  or  into  the  anterior  chamber,  and  is  due  to 
atrophy  or  laceration  of  the  zonule  of  Zinn.  In  either 
case  the  dislocation  is  apt  to  produce  glaucoma.  The 
operative  removal  of  a  dislocated  lens  from  the  eye  is  a 
most  precarious  and  ungrateful  undertaking  for  the  sur- 
geon, and  should  not  be  resorted  to  until  after  rest, 
miotics,  etc.,  have  failed  to  bring  about  the  desired  result. 
For,  as  the  lens  has  become  loosened  from  its  suspensory 
ligament,  its  removal  is  always  followed  by  the  escape  of 
much  vitreous  and  its  evil  consequences,  even  though  the 
operation  be  performed  under  anesthesia.  It  is  to  be 
remembered  that  in  dislocation  of  the  lens  into  the  vitreous 
it  is  often  very  difficult  to  get  a  firm  hold  of  the  lens  with 
a  snare  and  to  remove  it  rapidly.  It  is  apt  to  slip  to  one 
side  and  escape  from  the  snare.  In  any  case  the  corneal 
incision  must  be  large  enough,  otherwise  the  lens  can  not 
be  removed  from  the  globe  at  all. 

When  dislocation  of  the  lens  is  the  result  of  inflamma- 
tory degeneration,  it  is  best  to  enucleate  the  eye,  because 
recovery  after  extraction  of  the  lens  is  doubtful,  and  the 
operation  is  apt  to  produce  sympathetic  disease  of  the 
other  eye.  In  fact,  I  have  seen  that  develop  after  extrac- 
tion of  the  lens  in  the  case  of  traumatic  dislocation. 


176  OPERATIONS  ON  THE  EYE. 

Plate  5. 

Operation  fur  secondary  cataract  with  Knapp's  knife  introduced 
through  the  sclera. 

In  partial  dislocation,  when  the  lens  is  merely  displaced 
to  one  side  and  is  still  held  by  the  zonule  of  Zinn  on  the 
other,  discission  is  the  best  operation,  especially  in  youth- 
ful patients.  If  the  operation  is  performed  with  skill,  it 
is  usually  possible  to  spear  the  lens  with  one  of  the  dis- 
cission-needles,  and  tear  the  capsule  with  the  other  needle, 
making  only  a  moderately  large  opening,  so  that  the 
swelling  of  the  lens  will  not  be  too  great  and  the  pro- 
lapsing mass  of  lenticular  material  is  at  once  absorbed. 
Puncture  of  the  cornea  must  be  avoided  in  such  cases, 
because  it  would  be  followed  by  immediate  prolapse  of  the 
vitreous.  If  absorption  is  interrupted  a  needle  is  intro- 
duced into  the  opening  in  the  capsule,  and  the  lenticular 
substance  stirred  up,  or  the  opening  may  be  enlarged  with 
both  needles.  Increased  intra-ocular  tension  is  treated 
with  rest  in  bed  and  miotics. 

Although  this  method  is  somewhat  slow,  it  is  reliable 
and  yields  beautiful  results.  It  is  also  suitable  for  cases 
of  congenital  ectopia  of  the  lens  in  young  persons,  when 
the  tremor  of  the  lens  is  so  great  as  to  increase  the  intra- 
ocular tension  or  threaten  dislocation.  According  to  my 
experience  extraction  of  the  lens  in  these  cases  is  less 
advisable. 

Removal  of  the  Lens  in  Cases  of  High  Myopia. 

It  was  pointed  out  by  Beer,  in  1817,  and  by  Mauthner, 
in  1876,  as  well  as  by  others,  that  a  very  high  grade  of 
myopia  can  be  improved  by  removing  the  lens.  The 
relief  thus  effected  is  more  urgently  indicated,  as  it  is  im- 
possible to  wear  glasses  strong  enough  to  secure  good  vis- 
ion, because  the  eyes  will  not  tolerate  them. 

The  operation  for  myopia  was  first  performed  by  Ad. 
Weber  in  1858,  but  was  not  accepted  by  the  operators  of 
his  time,  chiefly  on  the  ground  of  its  danger,  and,  indeed, 


fi^V^  M 


REMOVAL  OF  LESS  IN  CASES  OF  HIGH  MYOPIA.    177 

it  was  quite  right  to  put  it  off  until  our  own  time.  It 
needs  the  extra  precaution  of  antisepsis  and  asepsis  to 
justify  this  grave  interference  in  cases  which  for  years 
have  been  regarded  as  dubious  from  the  operative  point  of 
view,  and  which  formerly  were  quite  rightly  regarded  as 
noli  me  längere.  Fukala  returned  to  the  method  thirty 
years  after  Weber's  time,  and  wrote  about  it  in  1889.  He 
was  followed  soon  after  by  Yacher,  in  France.  The 
operation  has  been  taken  up  with  great  enthusiasm,  per- 
haps with  excessive  enthusiasm.  On  the  strength  of  my 
own  experience  with  100  operations  of  this  kind  I  feel 
impelled  to  counsel  caution,  not  only  in  the  operation 
itself  but  also  in  the  selection  of  cases.  It  is  not  true 
that  disease  of  the  macula,  which  is  such  a  serious  menace 
to  the  eyesight,  does  not  occur  after  this  operation,  or  is 
brought  to  a  standstill.  If  such  eyes  are  used,  macular 
disease  often  develops,  and  is  quite  as  severe  as  in  eyes 
that  have  not  been  operated  upon.  The  more  intellectual 
among  these  patients,  who  wish  to  make  extensive  use  of 
their  improved  vision,  often  live  to  be  cruelly  disappointed, 
either  because  the  eyesight  again  becomes  irreparably  im- 
paired, or  the  physician  keeps  on  repeating  the  old  caution 
against  excessive  use  of  the  eyes. 

It  is  also  probable  that  those  who  have  been  operated 
upon  for  myopia  are  in  greater  danger  of  having  a  retinal 
detachment  than  those  who  have  not.  Unless  the  entrance 
of  vitreous  into  the  wound  during  the  operation  is  scrupu- 
lously avoided — which  requires  the  greatest  care — or  if 
the  vitreous  is  injured  at  the  final  discission  of  the  pos- 
terior capsule,  the  predisposing  factors  for  a  retinal  de- 
tachment are  furnished.  It  is  not  right  to  assume,  when 
a  retinal  detachment  does  not  occur  until  one  or  two  years 
later,  that  it  can  not  be  due  to  the  operation.  Moderate 
or  very  slight  injuries  to  the  vitreous  are  often  followed 
by  a  retinal  detachment  many  years  later. 

Since  the  primary  failures  alone  with  this  operation  in 
the  hands  of  individual  operators  amount  to  10  to  14  per 
cent.,  which  does  not  include  subsequent  deterioration  or 

12 


178  OPERATIONS  ON  THE  EYE. 

loss  of  vision,  the  greatest  caution  is  absolutely  indis- 
pensable. It  is  much  more  important  in  this  operation 
than  in  any  other  to  prevent  the  entrance  of  vitreous  into 
the  wound,  whether  the  latter  be  large  or  small.  Indi- 
viduals with  high  myopia  are  naturally  prone  to  retinal 
detachment.  In  the  second  place  infection  of  any  kind 
must  be  scrupulously  guarded  against.  Finally,  unless 
the  operation  is  correctly  performed  in  every  particular, 
such  eyes  are  exposed  to  the  danger  of  severe  glaucoma, 
and  the  literature  shows  that  many  an  eye  has  become 
blind  from  that  cause. 

To  escape  the  patient's  reproaches  and  a  great  deal  of 
trouble  the  operator  should  select  only  cases  in  which  the 
macula  is  still  in  a  fairly  good  condition,  the  myopia 
20  D.  or  more,  and  the  patient  young.  Moreover,  he 
should  choose  the  method  of  operating  with  which  he  is 
least  likely  to  see  anything  of  the  vitreous — that  is,  dis- 
cission— and  make  as  small  a  puncture  of  the  anterior 
chamber  as  he  can  get  along  with.  In  children  discission 
alone  and  absorption  suffice.  It  is  better,  if  possible,  to 
omit  the  final  discission  of  the  posterior  capsule ;  at  least 
it  should  never  be  done  earlier  than  six  mouths  after  the 
operation  and  after  the  eye  has  had  complete  rest  and  is 
free  from  irritation. 

Scrupulous  care  and  the  strongest  possible  light  are 
indispensable,  even  for  the  first  discission  of  the  ante- 
rior capsule,  in  order  to  guard  against  laceration  of  the 
zonule. 

Such  eyes  naturally  possess  a  weakened,  delicate  zonule, 
which  may  quite  easily  be  injured  at  the  first  opening  of 
the  capsule.  If  the  zonule  tears,  the  initial  puncture  or 
linear  extraction  will  be  attended  by  the  entrance  of 
vitreous  into  the  wound,  and  the  evacuation  of  the  catar- 
actous  masses  must  at  once  be  interrupted.  The  cataract 
continues  to  swell,  the  tension  is  increased,  a  second 
puncture  is  required,  vitreous  again  escapes  with  but  a 
small  quantity  of  lenticular  substance,  and  the  condition 
ends  in  glaucoma,  with  which  the  surgeon  will  have  to 


IRIDECTOMY.  179 

contend  fur  months  without  satisfactory  treatment  and 
without  success. 

It  therefore  follows  that,  when  the  capsule  is  first 
opened,  the  lens  must  not  be  pulled  to  and  fro  even  the 
width  of  a  hair,  nor  pushed  backward. 

In  order  to  evacuate  a  swollen  lenticular  mass  after  the 
discission,  a  fairly  large  corneal  incision  is  necessary ;  for 
when  the  lens  is  not  cloudy  the  cataractous  masses  are 
exceedingly  tenacious. 

Some  operators  prefer  to  remove  a  clear  lens,  even  in 
youthful  individuals,  by  the  same  operation  as  that  which 
is  employed  for  senile  cataract — that  is  to  say,  a  large 
incision  at  the  corneal  border,  opening  of  the  anterior 
chamber  without  preliminary  iridectomy,  and  expression 
of  the  lens.  The  ultimate  effects  of  this  procedure  have 
not  been  reported  in  sufficient  numbers  to  make  it  pos- 
sible to  form  a  judgment,  but  it  can  not  help  being  followed 
more  frequently  by  injury  of  the  vitreous  than  cautious 
discission. 

In  most  cases  it  is  advisable  to  operate  only  on  one  eye, 
so  that  the  other  eye  will  at  least  be  useful  for  near-sight 
and,  in  case  of  accident,  the  patient  does  not  become 
totally  blind. 

The  man  who  operates  on  a  myopia  of  less  than  15  D. 
brings  the  method  into  ill-repute.  The  patients  simply 
exchange  their  minus  glass  for  far-sight  for  a  plus  glass 
of  equal  strength,  and  lose  their  good  near-vision  without 
spectacles,  of  which  they  are  often  quite  proud.  After 
the  operation  they  have  to  wear  a  heavy  cataract  lens  of 
8  D.  or  more  for  near  work. 

II.   IRIDECTOMY. 

Iridectomy  as  an  independent  operation  is  performed 
chiefly  for  two  reasons.  First,  as  optical  iridectomy  to 
afford  the  rays  of  light  access  into  the  interior  of  the  eye 
when  the  normal  pupil  is  displaced  laterally  or  anteriorly 
by  inflammatory  exudate  or  distortion,  or  completely  cov- 


180  OPERATIONS  ON  THE  EYE. 

Figs.  60-66. — Instruments  for  iridectomy. 
Fig.  60. — Von  Grate's  stop-speculum. 
Fig.  61. — Curved  keratome,  seen  from  above. 
Fig.  62. — Curved  keratome,  seen  from  the  side. 
Fig.  63. — Fixation-forceps. 
Fig.  64. — Curved  iridectomy-scissors. 
Fig.  65. — Iris-forceps. 
Fig.  66. — Spatula  for  replacing  the  iris. 

Of  course,  instead  of  these  instruments,  others  that  serve  the  same 
purpose  may  be  used. 

ered  by  a  thick  central  corneal  opacity.  The  operation 
may  also  be  considered  when  there  is  a  stationary  central 
opacity  of  the  lens  (see  p.  112).  Second,  another  and 
much  more  important  reason  for  performing  iridectomy 
is  to  reduce  morbidly  increased  intra-ocular  tension  in 
glaucoma. 

i.  Optical   Iridectomy. 

This  operation,  which  originated  in  the  eighteenth  cen- 
tury, is  now,  as  a  rule,  performed  after  the  manner  pro- 
posed by  Beer  at  the  beginning  of  the  nineteenth  century. 

The  value  of  the  newly  formed  pupil  is  often  greatly 
diminished  by  the  fact  that  the  lateral  portions  of  the 
cornea  and  of  the  lens,  which  correspond  to  the  new 
pupil,  are  not  possessed  of  as  equally  good  refracting 
power  as  the  central  portion.  The  more  peripheral  the 
location  of  the  new  pupil  the  less  distinct  will  be  the 
retinal  image  that  it  makes  possible;  although  its  distinct- 
ness may  be  increased  by  means  of  a  cylindric  lens. 
Hence,  the  optical  result  of  the  measure  is,  as  a  rule, 
most  satisfactory  when  the  pupil  has  to  be  only  slightly 
displaced  to  one  side,  for  which  purpose  it  is  enough  to 
cut  a  small  piece  out  of  the  iris  near  the  pupil. 

It  must  never  be  forgotten  that  iridectomy,  unless  it  is 
covered  by  the  upper  lid,  may  distress  the  patient  by  ad- 
mitting too  much  light,  especially  in  cases  of  corneal 
opacity.  For,  if  the  pupil  is  not  adherent  to  the  lens, 
and  therefore  possesses  its  normal  mobility— as,  for  ex- 
ample, when  iridectomy  is  performed  solely  on  account  of 
a   corneal   opacity— the   pupil  will   remain    permanently 


182  OPERATIONS  ON  THE  EYE. 

dilated,  because  a  piece  of  the  sphincter  has  been  removed, 
and  the  normal  power  of  contraction  has  therefore  been 
impaired.  Corneal  opacities  often  produce  marked  blind- 
ing, because  they  act  like  a  ground-glass  and  diffuse  the 
light  into  the  eye.  The  annoyance  is,  of  course,  greater 
in  proportion  to  the  size  of  the  pupil  and  the  degree  of 
translucency  of  the  opacities.  In  such  cases  it  is  some- 
times necessary  to  blacken  the  central  corneal  opacity  by 
tattooing,  in  order  to  diminish  the  patient's  discomfort. 

It  is  altogether  wrong  to  make  an  optical  coloboma 
behind  an  opaque  cornea,  even  when  the  opacity  is  only 
slight.  The  vision  is  not  materially  improved  thereby, 
while  the  patient  is  annoyed  by  the  troublesome  blinding 
effect. 

If  optical  iridectomy  is  to  accomplish  its  purpose,  it 
must  be  wholly  or  at  least  partly  within  the  region  of 
the  palpebral  fissure.  If  the  greater  part  of  the  cornea 
is  opaque,  the  location  of  the  iridectomy  will,  of  course, 
have  to  be  determined  by  the  remaining  clear  tissue. 
A  clear  spot  may  be  tested  for  the  remaining  degree  of 
function  by  dilating  the  pupil  and  holding  a  disc  of  lead 
with  a  slit  in  it  in  front  of  the  eye,  in  various  meridians, 
until  the  position  is  found  where  vision  is  best,  which  will 
correspond  to  the  most  favorable  corneal  meridian.  Some- 
times it  may  be  necessary  to  give  the  patient  a  convex  or 
concave  lens  in  performing  the  test.  The  iridectomy 
should  then  be  placed  in  this  meridian,  care  being  observed 
to  excise  a  narrow  piece  of  the  curtain,  so  that  the  opening 
will  be  cleft-like  in  form.  A  diaphragm  with  a  small 
and  narrow  opening  yields  more  distinct  images  than  one 
with  a  large  opening. 

The  instruments  necessary  for  this  form  of  iridectomy 
are  shown  in  Figs.  60-66. 

After  the  eye  has  been  well  cleansed  and  cocainized, 
the  speculum  is  introduced,  and  the  operation  is  usually 
performed  with  a  narrow,  or  only  moderately  broad, 
curved  keratome  (Figs.  61  and  62).  In  cutting,  the 
operator  may  carry  the  instrument  away  from  his  body, 


OPTICAL  IB  IDECTO  MY.  183 

or  he  may  carry  it  toward  it ;  but  in  the  latter  case  he 
will  have  to  change  his  position  with  relation  to  the 
patient.  For  example,  in  doing  an  iridectomy  on  the  left 
eye  at  the  inner  and  lower  angle,  which  is  often  selected 
for  optical  iridectomy,  the  operator,  if  he  wishes  to  cut 
toward  his  body,  stands  to  the  right  side  of  the  patient ; 
and  if  he  wishes  to  cut  away  from  his  body,  to  the  left  of 
the  patient.  For  excising  a  small  segment  of  the  iris,  the 
knives  shown  in  Figs.  76  and  78  may  also  be  used  to  ad- 
vantage. With  these  instruments  a  small  wound  is  made 
in  the  cornea  which,  however,  must  not  be  too  narrow  on 
the  side  toward  the  anterior  chamber,  so  that  there  may 
not  be  much  difference  between  the  inner  and  the  outer 
wound.  It  should  also  be  remembered  that  instead  of  an 
iris-forceps  (Fig.  65)  a  blunt  iris-hook  (Figs.  67  and  68) 
is  also  quite  useful  in  optical  iridectomy,  especially  when  it 
is  desired  to  seize  only  a  small  piece  near  the  pupil.  It 
requires  only  a  small  incision  in  the  cornea  to  introduce 
the  hook  into  the  anterior  chamber,  and,  as  it  is  blunt, 
there  is  no  danger  of  injuring  the  lens.  Besides,  seizing 
the  iris  with  the  hook  is  a  painless  procedure  (Axenfeld), 
which  makes  it  easier  to  place  the  iridectomy  correctly. 
The  instrument  is  introduced  flat  over  the  iris,  then 
slightly  rotated  to  seize  the  edge  of  the  pupil,  and  drawn 
out  again  flat.  It  has  the  advantage  of  permitting  the 
incision  to  be  made  at  the  limbus  of  the  sclera,  leaving 
the  cornea  free  from  any  incision,  and  therefore  obviating 
any  danger  of  a  consequent  permanent  opacity,  which 
sometimes  partially  interferes  with  the  newly  formed 
coloboma. 

The  globe  is  fixed  opposite  the  point  where  the  keratome 
is  introduced.  After  the  assistant  has  taken  charge  of  the 
fixation-forceps,  the  operator  introduces  the  finely  serrated 
iridectomy-forceps  (closed),  seizes  the  iris  near  the  edge 
of  the  pupil,  draws  it  out  in  front  of  the  wound,  and 
snips  off  the  fragment  with  the  bent  iridectomy-scissors. 
When  a  narrow  iridectomy  is  desired,  the  iris,  after  it  has 
been  drawn  out  through  the  wound,  is  excised  in  a  radial 


184  OPERATIONS  ON  TUE  EYE. 

Fig.  67.— Blunt  iris-hook. 
Fig.  68.— Blunt  iris-hook. 
Fig.  69. — Sharp  iris-hook. 
Fig.  70. — Sharp  iris-hook. 
Fig.  71.— Single  hook. 
Fig.  72.— Double  hook. 

direction.  If,  on  the  other  hand,  it  is  desired  to  have  the 
coloboma  reach  as  far  as  the  periphery,  the  curtain  is  cut 
off  along  a  line  parallel  to  the  wound.  Instead  of  the 
usual  iridectomy-scissors,  Wecker's  scissors  may  also  be 
used.  After  the  excision,  the  iris  is  carefully  replaced 
with  the  spatula  (Fig.  66).  The  same  thing  must  be 
done  when  the  iris  has  been  seized  with  a  hook  in  making 
a  coloboma. 

A  single  bandage  must  be  worn  for  from  five  to  six 
days,  and  the  patient  remains  in  bed  twenty-four  hours. 
He  should  be  kept  under  supervision  for  from  eight  to  ten 
days,  when  recovery  will  have  taken  place.  As  a  rule, 
there  is  no  complicating  inflammation. 

Forming  the  transition  from  optical  iridectomy  to  iridec- 
tomy performed  for  the  relief  of  tension  there  is  the  opera- 
tion performed  for  the  purpose  of  preventing  secondary 
glaucoma.  When  the  pupil  is  adherent  around  the  entire 
periphery,  or  there  is  only  a  small  gap  left  in  the  circular 
synechia,  it  is  better  not  to  wait  until  the  tension  has 
actually  increased  and  irritation  and  sensitiveness  have 
made  their  appearance ;  it  is  much  better  to  take  advan- 
tage of  the  time  when  the  eye  is  at  rest  to  make  an  open- 
ing in  the  iris  for  the  purpose  of  restoring  communication 
between  the  space  behind  the  iris  (the  posterior  chamber) 
and  the  anterior  chamber,  as  sooner  or  later  there  is  danger 
of  bulging  of  the  iris  from  an  accumulation  of  aqueous 
humor  behind  it,  producing  an  increase  of  tension. 

In  this  form  of  iridectomy  the  upper  segment  of  the 
eye  is  usually  selected.  The  excised  portion  need  not  be 
broad.  A  moderately  broad  keratome  is  introduced  at  the 
scleral  border.  After  the  iris  has  been  seized  with  the 
forceps  it  is  slowly  drawn  out,  because  the  adhesion  be- 


r     1 


69 


JO  71 


185 


186  OPERATIONS  ON  THE  EYE. 

tween  the  piece  of  iris  and  the  lens  has  to  be  separated. 
In  some  cases,  if  the  adhesion  is  very  dense,  the  edge  of 
the  pupil  remains  behind  on  the  lens,  where  it  should  then 
be  allowed  to  remain. 

Even  in  case  of  an  extensive  anterior  synechia — that  is, 
an  adhesion  between  the  iris  and  the  cornea  as  a  result  of 
perforation,  with  ulcer  or  injury  of  the  latter — it  is  often 
advisable  not  to  wait  for  secondary  glaucoma,  which  is  so 
apt  to  follow  this  condition,  but  to  relieve  the  pressure 
on  the  iris  by  iridectomy  as  soon  as  the  eye  has  been 
quiescent  for  some  time. 

2.  Iridectomy  for  the   Relief  of  Increased  Tension. 

As  the  object  is  not  to  improve  vision,  the  iridectomy 
should,  whenever  possible,  be  covered  by  the  upper  lid, 
and  a  broad  piece  of  the  iris  extending  to  the  periphery 
should  be  removed. 

The  discovery  that  iridectomy  cures  glaucoma  is  the 
immortal  achievement  of  Albr.  von  Gräfe  (1856).  Before 
his  discovery,  all  eyes  affected  with  glaucoma,  without 
exception,  went  blind  after  a  longer  or  shorter  space  of 
time.  The  fifty  years  that  have  elapsed  since  then  have 
shown  that  iridectomy,  when  performed  in  time,  is  the 
best  method  of  treating  glaucoma,  but  that  in  advanced 
and  chronic  cases  the  cure  effected  by  this  means  is  not 
certain  nor  always  permanent ;  for  relapses  occur  even 
when  the  operation  has  been  correctly  performed.  In 
hemorrhagic  glaucoma,  iridectomy  usually  fails  to  have 
the  desired  effect  and  may  indeed  do  more  harm  than 
good.  As  in  old  cases  of  ordinary  glaucoma  iridectomy 
may  make  matters  worse,  the  chief  indications  for  iridec- 
tomy in  cases  belonging  to  the  group  of  primary  glaucoma 
are  acute  and  subacute  glaucoma,  and  simple  glaucoma 
when  not  too  far  advanced — that  is,  when  there  is  not 
much  narrowing  of  the  visual  field  from  the  nasal  side. 
In  childhood,  if  the  child  is  not  very  young  and  the 
glaucoma  not  very  far  advanced,  iridectomy  may  be  tried  ; 


IRIDECTOMY  FOR  RELIEF  OF  INCREASED  TENSION.  187 

but  in  all  other  cases  of  infantile  glaucoma  sclerotomy  is 
to  be  preferred.  The  latter  operation  is  more  advisable 
also  in  advanced  cases  of  simple  glaucoma  and  hemor- 
rhagic glaucoma,  although  it  sometimes  has  to  be  repeated 
several  times. 

In  secondary  glaucoma,  iridectomy  is  indicated  when 
there  is  a  circular  synechia.  In  the  remaining  varieties 
of  secondary  glaucoma,  sclerotomy  or  puncture  of  the 
cornea  usually  suffice. 

The  eye  should  be  prepared  for  a  glaucoma  iridectomy 
by  the  instillation  of  miotics  (physostigmin  and  pilocar- 
pi), and  this  preparatory  treatment  is  the  more  necessary 
the  shallower  the  anterior  chamber,  because  it  enables  the 
operator  to  carry  out  the  operation  correctly.  The  deeper 
the  anterior  chamber  and  the  narrower  the  pupil — two 
conditions  that  are  brought  about  or  favored  by  the  use  of 
miotics — the  easier  it  is  to  introduce  the  keratome  cor- 
rectly, and  the  more  effective  will  be  the  excision  of  the 
iris.  Other  preparatory  measures  include  rest  in  bed  and 
judicious  use  of  morphin  to  induce  as  much  sleep  as  pos- 
sible ;  for  sleep  has  a  favorable  effect  on  the  intraocular 
tension.  It  is  not  wise,  however,  to  spend  more  than 
twelve  to  twenty-four  hours  in  preparing  a  patient  for 
operation  in  cases  of  acute  glaucoma.  If  by  that  time 
the  anterior  chamber  has  not  become  deep  enough,  either 
a  preparatory  sclerotomy  should  be  performed  or  an  iri- 
dectomy should  be  effected  with  a  narrow  knife  or  by  in- 
cising from  without. 

Preliminary  local  anesthesia  with  cocain  and  adrenalin 
is  most  important.  [In  acute  glaucoma,  when  not  contra- 
indicated  by  physical  conditions,  general  anesthesia  is 
preferable. — Ed.]  What  was  said  above  on  p.  31  ap- 
plies to  these  cases.  It  is  also  necessary  to  instil  physos- 
tigmin (eserin)  into  the  other  eye  for  some  time  before 
operating,  in  order  to  guard  it  against  an  attack  of  glau- 
coma from  the  excitement  of  the  operation.  [Eserin 
should  be  used  on  the  unoperated  eye  during  the  conva- 
lescence from  the  iridectomy.     Both  eyes  should  be  band- 


188  OPERATIONS  ON  THE  EYE. 

Plate  6. 

Iridectomy  in  glaucoma. 

aged  until  the  iridectomy  wound  has  healed  and  the 
anterior  chamber  is  restored. — Ed.] 

It  is  more  important  in  this  instance  than  in  any  other 
to  see  that  the  patient  is  in  a  proper  position.  If  the 
operation  is  painful,  an  unduly  soft  and  yielding  pillow 
will  permit  the  patient  to  draw  the  head  back,  and  thus 
greatly  endanger  the  success  of  the  procedure.  The  head 
should  therefore  be  placed  on  some  hard  substance  and 
held  very  firmly,  so  as  to  keep  it  absolutely  immovable 
during  the  painful  process  of  drawing  out  and  cutting  off 
the  iris. 

The  light  for  this  form  of  iridectomy  must  be  at  least 
as  good  as  for  a  cataract  operation. 

(a)  In  the  great  majority  of  cases  the  keratome  is  to  be 
preferred  for  iridectomy,  because  the  wound  which  it 
makes,  as  a  rule,  heals  more  quickly  and  more  kindly 
than  a  wound  made  with  a  narrow  knife.  It  is  true  that 
the  latter  is  easier  to  handle  and,  perhaps,  would  be  better 
for  a  beginner  to  use  instead  of  the  keratome,  which  is 
often  very  difficult  to  manage  when  the  anterior  chamber 
is  narrow,  and  always  places  the  lens  in  some  danger. 

After  the  conjunctival  sac  has  been  lightly  flushed  out, 
or,  if  the  irritation  is  severe,  without  that  preliminary 
precaution,  the  stop-speculum  is  inserted,  the  globe  firmly 
held  below  with  the  fixation-forceps,  and  the  keratome 
introduced  from  above  into  the  anterior  chamber,  either  as 
shown  in  Plate  6 — that  is,  the  operator  stands  at  the 
patient's  head  and  pushes  the  keratome  away  from  his 
body — or  he  stands  by  the  side  of  the  patient  and,  after 
introducing  the  keratome,  pushes  it  toward  his  body. 
The  keratome  is  introduced  2  mm.  from  the  transparent 
edge  of  the  cornea  and  advanced  in  such  a  way  as  to 
make  the  incision  parallel  with  the  corneal  border.  In 
old  persons  with  deep-set  eyes  it  is  often  necessary,  in 
order  t<>  sref   at  the  eve,  to  draw  the  flaccid  skin  of  the 


X 


IRIDECTOMY  FOR  RELIEF  OF  INCREASED  TENSION.  189 

upper  lid  upward  with  the  fourth  finger  (see  Plate  6). 
The  keratome  should  be  introduced  as  far  as  possible, 
without,  however,  injuring  Descemets  membrane  with  the 
point.  It  is  also  necessary  in  introducing  it  to  avoid 
pricking  the  iris  or  even  the  lens.  In  the  same  way,  when 
the  instrument  is  withdrawn,  the  operator  must  be  careful 
not  to  scratch  the  lens  with  the  point.  It  is  therefore 
better  to  depress  the  handle  toward  the  patient's  brow, 
and  to  bring  out  the  point  along  the  posterior  surface  of 
the  cornea,  but  without  touching  the  membrane. 

If  the  anterior  chamber  is  shallow  and  it  is  impossible 
to  advance  the  keratome  far  enough,  the  incision  may  be 
enlarged  to  one  side  as  the  instrument  is  withdrawn  by 
turning  the  point  in  that  direction  and  cutting  as  it  is 
withdrawn.  It  is  always  well  to  press  the  keratome 
against  the  iris,  in  order  to  prevent  prolapse  of  the  latter 
from  the  wound. 

The  excision  of  the  iris,  which  now  follows,  requires  a 
good  assistant  and  perfect  fixation  of  the  patient's  head, 
if  the  eye  is  sensitive.  If  the  iris  remains  in  the  anterior 
chamber,  as  is  best  for  a  regular  iridectomy,  the  curved 
iris-forceps  (Fig.  65)  is  introduced  (closed)  nearly  as  far  as 
the  pupillary  border;  it  is  then  opened  about  3  to  4  mm., 
and  the  iris  is  seized.  The  assistant,  to  whom  the  oper- 
ator has  given  the  fixation-forceps  after  completing  the 
incision,  now  has  the  important  task  of  holding  the  globe 
rigidly  and  preventing  it  from  rotating  tip  ward,  because  as 
soon  as  the  sensitive  iris  has  been  seized  with  the  forceps 
and  drawn  out  the  patient  reflexiv  rotates  the  eyeball 
upward  in  proportion  to  the  severity  of  the  pain.  This 
upward  rotation  makes  it  difficult  or  even  impossible  to 
draw  the  iris  forward  properly  and  cut  it  off  as  it  should 
be  done.  But  the  assistant  must  not  depend  solely  on 
the  conjunctiva,  in  the  grasp  of  the  forceps,  to  draw  the 
globe  downward,  because,  as  this  operation  is  frequently 
performed  on  old  persons  with  friable  conjunctiva?,  the 
membrane  would  simply  tear,  and  fixation  would  be  at  an 
end.     He  must,  on  the  contrary,  utilize  the  sharp  corners 


190  OPERATIONS  ON  THE  EYE. 

of  the  forceps  for  fixation  by  pressing  them  into  the 
sclera,  and  thus  strengthening  his  hold  on  the  globe.  For 
that  purpose  the  forceps  must,  of  course,  be  brought  into 
a  more  vertical  position  in  relation  to  the  globe  than  as 
shown  in  Plate  6  ;  and  if  the  globe  shows  a  tendency  to 
escape  upward,  it  must  be  pushed,  rather  than  drawn, 
downward. 

After  the  operator  has  drawn  the  iris  out  about  5  to  6 
mm.  from  the  anterior  chamber  he  holds  the  curved  iri- 
dectomy-scissors  with  the  convex  surface  against  the 
globe,  seizes  the  extracted  iris  between  its  blades,  and 
cuts  off  the  membrane  with  one  snip  of  the  scissors,  mak- 
ing slight  traction  on  the  iris  at  the  same  time ;  or  he  first 
cuts  off  half  of  the  drawn-out  iris  and  then  the  other, 
again  making  vigorous  traction  on  the  membrane.  For  it 
is  necessary  to  excise  a  broad  piece  of  the  iris,  extending 
as  far  as  the  peripheral  insertion  of  the  membrane,  so  as 
not  to  leave  any  more  of  the  iris  at  the  angle  of  the 
chamber  than  is  absolutely  unavoidable.  For  that  reason 
it  is  indispensable  to  hold  the  scissors  firmly  against  the 
globe  while  cutting.  Wecker' s  forceps-scissors  (Fig.  53) 
are  also  an  excellent  instrument  for  cutting  off  the  iris. 
If  the  iris  prolapses  in  front  of  the  wound  as  the  kera- 
tome  is  withdrawn,  it  should  be  seized  transversely  and 
cut  off  as  described. 

In  this  operation  also  it  is  necessary  to  replace  the  iris 
with  the  spatula  (Fig.  6ti)  after  the  excision  has  been 
completed  (see  Plate  3).  Indeed,  to  leave  the  iris  in  the 
angles  of  the  wound  would  be  particularly  dangerous  in 
glaucoma,  because  it  would  be  followed  by  an  increase  in 
the  tension.  The  corners  of  the  sphincter  must  be  re- 
placed in  such  a  way  as  to  correspond  with  the  normal 
border  of  the  pupil,  so  that  the  latter,  with  the  coloboma, 
resembles  an  inverted  keyhole.  It  is  well  to  have  the 
coloboma  somewhat  wider  above — that  is,  at  the  periphery 
of  the  iris — than  at  the  edge  of  the  pupil  (Fig.  8).  Quite 
frequently  in  iridectomies  for  glaucoma  the  iris,  which 
has  been  paralyzed  by  the  increased  tension,  is  slow  to 


IRIDECTOMY  FOR  RELIEF  OF  INCREASED  TENSION.  191 

return  to  it*  normal  position.  This  may  be  expected 
when  the  pupil  refuses  to  contract  in  ,-pite  of  appropriate 
preparatory  treatment,  and  the  iridectomy  has  to  be  per- 
formed with  a  dilated  pupil. 

Often  the  dilatation  of  the  pupil  in  glaucoma  is  greatest 
at  its  upper  portion,  and  only  a  narrow  hem  of  iris  re- 
mains for  excision.  This  disturbing  factor  and  a  deep 
position  of  the  eyeball,  with  a- tendency  to  rotate  upward, 
which  is  often  present  in  glaucomatous  patients,  who  are 
usually  advanced  in  years,  sometimes  render  it  advisable 
to  place  the  iridectomy  along  the  temporal  or  lower  por- 
tion of  the  curtain  instead  of  above,  particularly  in  cases 
of  advanced  glaucoma,  in  which  the  operation  is  per- 
formed more  for  the  purpose  of  relieving  pain  and  saving 
the  globe  than  to  improve  vision.  In  every  iridectomy, 
and  particularly  when  it  is  performed  for  glaucoma,  it  is 
important  to  avoid  the  error  of  introducing  the  keratome 

at  too  great  an  angle  through  the  cornea  (Fig.  72r/, ), 

as  that  would  bring  the  inner  wound  too  far  away  from 
the  outer  wound,  and  therefore  too  near  the  center.  The 
wound  should  be  as  near  as  possible  to  the  angle  of  the 
chamber  ( ),  because  that  is  the  only  way  that  ade- 
quate incision  of  the  iris  is  possible.  It  is  obvious  from 
Fig.  72a  that  the  correct  incision  would  come  into  col- 
lision with  the  iris.  Hence,  after  the  keratome  has  been 
advanced  in  the  direction  of  this  line 
as  far  as  the  iris  will  permit,  the 
handle  must  be  gradually  depressed 
in  order  that  the  point  may  miss  the 
iris  and  anterior  pole  of  the  lens. 
The  figure  also  shows  that  the  sclera  ^S^ST^^yä- 
overlaps  the  cornea  somewhat  at  the  cision  for  iridectomy. 
corneal  border.     Hence  an  incision 

2  to  3  mm.  from  the  corneal  border  will  encroach  upon  the 
cornea  with  its  inner  edge  (which  lies  in  Descemet's  mem- 
brane) or,  in  other  words,  if  the  inner  edge  of  the  wound 
is  to  be  placed  within  the  corneal  border — or  angle  of  the 


192  OPERATIONS  ON  THE  EYE. 

chamber — the  outer  wound  must  lie  within  the  sclera,  2  to 
3  mm.  from  the  edge  of  the  cornea. 

(6)  When  iridectomy  is  performed  with  Grafts  cataract 
knife,  there  is  less  danger  of  pricking  the  lens,  and  the 
mistake  just  referred  to  is,  therefore,  more  readily  avoided ; 
but  an  incision  made  with  this  instrument,  as  a  rule,  does 
not  close  so  easily,  and  the  operator  is  apt  to  fall  into  the 
error  of  coming  out  too  near  the  periphery,  and  having  a 
prolapse  of  the  lens,  either  during  or  after  the  operation, 
as  the  lens  may  be  forced  out  by  the  intra-ocular  tension 
if  the  latter  does  not  rapidly  diminish  after  the  operation. 
Occasionally  it  takes  several  days  for  this  to  occur.  Hence, 
although  the  length  of  the  wound,  which  should  be  from 
6  to  7  mm.,  has  a  most  favorable  effect  in  curing  the  glau- 
coma, too  large  a  wound  must,  for  the  reasons  given,  be 
avoided. 

The  Gräfe  knife,  which  should  be  very  narrow,  is  car- 
ried through  the  anterior  chamber,  as  in  an  operation  for 
cataract,  except  that  the  point  of  entrance  and  point  of 
exit  should  not  be  more  than  6  to  8  mm.  apart.  The  in- 
cision, which  should  be  at  the  scleral  border,  should  be 
about  2  mm.  from  the  edge  of  the  cornea  at  every  point 
along  its  entire  length.  With  this  instrument  also  it  is 
often  difficult,  on  account  of  insufficient  depth  of  the  an- 
terior chamber,  to  get  through  between  the  cornea  and 
the  iris,  and  succeed  in  making  a  sufficiently  long  in- 
cision. 

Excision  of  the  iris  and  replacement  are  performed  in 
the  same  way  as  before  described. 

(c)  Iridectomy  by  incision  with  scalpel  or  scarifier 
(Gay et,  Schöler).  Whereas,  when  the  incision  is  made 
with  the  Gräfe  knife,  as  just  described,  the  anterior 
chamber  is  opened  from  within  outward,  it  may  also  be 
opened  from  without  inward,  either  with  the  same  knife 
or,  still  better,  with  a  broader-bellied  knife,  as,  for  ex- 
ample, the  scarifier  mentioned,  or  a  very  sharp  scalpel. 
This  method  is  advisable  when  there  is  little  or  no  room 
between  the  cornea  and  the  iris  because  the  curtain  has 


IRIDECTOMY  FOR  RELIEF  OF  INCREASED  TENSION.  193 

been  pushed  too  far  forward,  either  owing  to  severe 
primary  glaucoma  or,  very  frequently,  from  secondary 
glaucoma,  with  bulging  of  the  iris,  as  a  result  of  a  cir- 
cular, or  a  large  anterior,  synechia  (for  example,  after  a 
large  central  perforating  ulcer).  In  such  a  case  the  in- 
cision is  made  cautiously  from  without  inward  along  the 
corneal  or,  better,  the  scleral,  border.  The  incision  by 
which  the  anterior  chamber  is  opened  is  first  made  short 
and  then  enlarged  with  suitable  scissors,  [de  Wecker's 
(Fig.  53),  Stevens'  (Fig.  92),  or  Desmarres'  (Fig.  36),]  the 
instrument  being  brought  into  play  at  the  angle  of  the 
chamber  between  the  cornea  and  the  iris. 

So  far  we  have  succeeded  no  better  in  explaining  the 
effect  of  iridectomy  in  primary  glaucoma  than  we  have  in 
explaining  this  form  of  glaucoma  itself.  The  thought 
naturally  suggests  itself  that  incision  of  the  capsule  of 
the  globe  is  followed  by  increased  seepage  of  aqueous 
humor  from  the  anterior  chamber — in  other  words,  a  so- 
called  filtration -scar  is  produced  and  furnishes  a  kind  of 
safety-valve,  protecting  the  eye  from  excessive  pressure. 
On  these  grounds  de  Wecker  recommended  simple  in- 
cision at  the  corneoscleral  border  without  iridectomy, 
under  the  name  of  sclerotomy,  and  used  it  in  the  treat- 
ment of  glaucoma.  It  was  found,  however,  that  the 
effect  of  this  procedure  was  not  as  great  as  that  of  iridec- 
tomy, and  that  excision  of  a  piece  of  iris  reduced  the 
excessive  tension  better  than  more  incision,  at  least  during 
the  initial  stage  of  the  process.  It  can  not  be  denied  that 
sclerotomy  acts  well  in  the  later  stage  of  glaucoma  and  in 
children,  and  that  it  is  possible,  therefore,  that  part  of  the 
effect  of  an  iridectomy  is  to  be  attributed  to  the  increased 
seepage  (filtration). 

Since  it  appears,  from  the  investigations  of  Knies  and 
Ad.  Weber,  that  obliteration  of  the  angle  of  the  anterior 
chamber  (Fontana's  space)  plays  an  important  part  in  the 
causation  of  glaucoma,  and  has  even  been  considered  the 
primary  cause  of  the  disease,  the  good  effect  of  ex- 
cising a  piece  of  the  iris  has  been  explained   by  the  open- 

13 


194  OPERATIONS  ON  THE  EYE. 

ing  up  of  the  angle  of  the  anterior  chamber  so  far  as  it 
falls  within  the  influence  of  the  iridectomy.  As  a  matter 
of  fact,  however,  the  angle  is  opened  up  only  when  the 
iris  is  extirpated  as  far  as  its  root,  which,  as  appears  from 
the  anatomical  investigations  of  Treacher  Collins,  is  not 
the  case  as  a  rule.  In  23  eyes  which  had  been  iridec- 
tomized  for  glaucoma  he  found  that  in  only  2  the  oper- 
ative scar  extended  near  enough  to  the  periphery  for  the 
incision  to  have  involved  the  ligamentum  pectinatum.  In 
3  cases,  in  which  the  incision  had  been  carried  very  near 
the  periphery,  the  increase  in  tension  had  returned. 
Nevertheless,  it  may  be  assumed  that  the  removal  of  a 
piece  of  iris  renders  the  angle  of  the  chamber  more  access- 
ible, and  thus  improves  the  drainage. 

Priestley  Smith's  theory  that  the  way  is  prepared  for 
glaucoma  chiefly  by  the  physiologic  increase  in  the  size  of 
the  lens — which  occurs  in  advanced  age — furnishes  another 
possible  explanation  of  the  favorable  eifect  of  iridectomy 
and  sclerotomy.  As  the  lens  increases,  the  space  between 
it  and  the  ciliary  body  diminishes,  and  if  the  ciliary 
processes  become  engorged  with  blood,  the  edge  of  the 
lens  and  the  ciliary  process  may  force  the  root  of  the  iris 
forward,  thus  narrowing  or  even  occluding  the  angle  of 
the  anterior  chamber.  This  mechanism  would  render  the 
effect  of  iridectomy  intelligible,  because  the  iris,  at  all 
events,  could  not  be  pushed  forward  at  the  site  of  the 
iridectomy  ;  and  there  is  another  factor — for  Snellen  ob- 
served that  every  successful  operation  is  followed  by  quite 
a  considerable  flattening  of  the  cornea  in  the  direction 
toward  the  operative  wound.  This  flattening  is  neces- 
sarily accompanied  by  a  certain  dilatation  of  the  bulbar 
wall  in  the  ciliary  region,  and  in  that  way  there  is  pro- 
duced a  dilatation  of  the  perilenticular  space,  which,  ac- 
cording to  Priestley  Smith's  theory,  must  have  a  favorable 
effect  on  the  circulatory  conditions  in  that  region. 

The  after-treatment  of  a  glaucoma  iridectomy  requires, 
first  of  all,  a  few  days'  rest  in  bed,  which  has  a  favorable 
effect  on  intra-ocular  tension.     The  use  of  miotics  is  in- 


IRIDECTOMY  FOR  RELIEF  OF  INCREASED  TENSION.  195 

dicated  very  soon  after  the  operation,  sometimes  even  on 
the  first  day.  Pilocarpin,  2  to  3  per  cent,  solution,  five  to 
six  times  a  day,  if  necessary,  is  to  be  preferred  for  post- 
operative use,  as  it  is  less  irritating  than  physostigmin 
(eserin).  Iridectomy  wounds  also  must  be  kept  clean,  to 
guard  against  iritis.  Even  sympathetic  disease  of  the 
other  eye  has  been  known  to  occur  after  an  iridectomy  for 
glaucoma. 

The  most  important  complication  during  convalescence 
is  failure  of  the  wound  to  close,  because  the  tension  fails 
to  diminish  after  the  operation.  In  such  unfavorable 
cases,  posterior  sclerotomy  has  been  recommended,  com- 
bined, if  necessary,  with  Weber's  procedure  (see  Scle- 
rotomy). 

Total  escape  of  the  lens,  which  sometimes  does  not  take 
place  until  after  the  operation,  and  occurs  when  the  in- 
cision is  too  near  the  periphery,  or  too  large,  is  undesirable, 
but  is  better  than  mere  prolapse  of  the  lens  into  the 
wound,  which  causes  renewed  increase  of  tension.  Hence, 
the  accident  may  have  a  favorable  effect. 

Retinal  hemorrhages  occurring  after  the  operation  pos- 
sess little  significance  and  are  probably  caused,  as  a  rule, 
by  the  introduction  of  the  intra-ocular  tension  which  fol- 
lows incision  of  the  globe,  and  brings  about  rapid  change 
of  pressure  in  the  retinal  vessels.  Such  a  hemorrhage  is 
not  a  sign  that  the  glaucoma  belongs  to  the  hemorrhagic 
form.  But  if  the  hemorrhage  takes  place  before  the 
operation,  it  is  a  sign  of  hemorrhagic  glaucoma. 

In  addition  to  the  two  above-mentioned  principal  indi- 
cations for  iridectomy,  and  iridectomy  as  a  preliminary 
operation  for  cataract  extraction,  which  has  been  referred 
to,  certain  less  frequent  indications  should  be  mentioned. 

3.  Iridectomy  in  chronic  iritis  to  prevent  relapses  and 
clear  up  the  vitreous.  This  operation  has  lost  much  of 
its  former  popularity,  at  least  among  those  who  only  per- 
form necessary  operations.  At  any  rate  it  must  be  per- 
formed only  during  an  interval  of  entire  freedom  from 
inflammation,  and  even  then  the  gap  in  the  iris  closes  up 


196  OPERATIONS  ON  THE  EYE. 

again,  usually  after  a  large  hemorrhage,  which  more  or 
less  completely  fills  the  anterior  chamber.  In  the  same 
way  the  relief  obtained  by  iridectomy  in  cases  of  obstinate 
and  troublesome  flocculi  in  the  vitreous  is  often  but  slight. 
It  is  an  absolute  mistake  to  operate  on  account  of  a  few 
synechia?.  The  view  which  was  held  several  decades  ago, 
that  synechia?  produce  a  fresh  iritis,  has  lost  weight  since 
we  know  that  iritis  is  usually  due  to  a  constitutional  cause. 

4.  In  cases  of  ectatic  scars  of  the  cornea  and  staphy- 
loma-formation,  iridectomy  is  perfectly  justifiable  and,  as  a 
rule,  reduces  the  bulging  in  both  of  these  conditions. 

5.  Iridectomy  may  be  tried  for  the  purpose  of  removing 
very  small  sarcomatous  nodules  on  the  iris.  According 
to  my  experience  the  best  procedure  in  such  cases  is,  first, 
to  make  a  large  incision  at  the  corneal  border,  equivalent 
to  ^  or  ^  of  the  circumference  of  the  membrane,  if  neces- 
sary, with  the  scissors,  and  then  to  perform  an  iridectomy 
to  the  right  and  left  of  the  nodule.  In  that  way  the  piece 
of  iris  containing  the  tumor  may  be  completely  rolled  out 
of  the  anterior  chamber  and  removed,  to  the  very  root  of 
the  iris. 

In  the  case  of  tuberculous  proliferations  it  is  better  not 
to  extirpate,  but  to  treat  them  either  by  introducing  iodo- 
form into  the  anterior  chamber  or  by  tuberculin  injections 
or  enucleation. 

III.  SCLEROTOMY. 

As  has  been  mentioned,  anterior  sclerotomy — that  is, 
sclerotomy  performed  at  the  corneal  margin,  represents 
one-half,  and  under  certain  circumstances  the  better  one- 
half,  of  iridectomy  ;  for  it  is  always  a  less  dangerous  pro- 
cedure, although  not  quite  so  effective  as  iridectomy  ;  but 
it  can  be  repeated  as  often  as  may  be  desirable.  In  infan- 
tile glaucoma,  in  advanced  cases  of  glaucoma,  and  in  hem- 
orrhagic glaucoma  I  believe,  from  my  experience,1  that  it 

1  Up  to  June,  1900,  I  had  performed  570  operations  on  303  adults 
suffering  from  glaucoma — 279  iridectomies  and  291  sclerotomies;  up  to 
November,  1899,  I  had  performed  104  sclerotomies  on  84  children 
affected  with  glaucoma. 


SCLEROTOMY.  197 

is  preferable  to  iridectomy,  and  in  the  remaining  forms  of 
glaucoma  it  is  often  a  useful  accessory  or  complementary 
operation  ;  for  in  many  of  the  cases  of  glaucoma  that  pre- 
sent themselves  late  for  treatment  iridectomy  fails  to  effect 
a  permanent  cure,  and  sooner  or  later  a  secondary  operation 
becomes  necessary. 

In  the  presence  of  iridocyclitis  with  deposits,  causing 
increased  tension,  sclerotomy  is  the  proper  operation  and 
iridectomy  would  be  altogether  out  of  place.  In  kerato- 
conus,  repeated  sclerotomy  is  indicated — to  arrest  the  prog- 
ress of  the  disease. 

Sclerotomy  may  be  performed  either  with  the  keratome 
(Quaglino,  Snellen)  or  with  the  cataract-knife.  The  latter 
method,  proposed  by  Wecker,  makes  it  possible  to  avoid  a 
prolapse  of  the  iris,  which  is  always  apt  to  occur  when 
the  keratome  is  used.  The  Gräfe  knife  is  introduced 
much  in  the  same  way  as  in  the  operation  for  cataract  (see 
Plate  7),  except  that  the  points  of  entrance  and  exit  lie 
farther  out  on  the  sclera ;  the  knife  is  drawn  to  and  fro 
with  a  sawing  movement,  as  though  for  the  purpose  of 
making  a  curved  incision  in  the  corresponding  direction 
(below  in  Plate  7) ;  but  after  the  entrance  and  exit  wounds 
have  been  enlarged  to  about  3  mm.,  a  broad  bridge  of 
sclera  is  allowed  to  stand,  the  point  of  the  knife  as  it  is 
withdrawn  being  carried  over  the  inner  surface  of  the 
sclera  in  the  angle  of  the  anterior  chamber.  But  in  thus 
incising  the  inner  angle  of  the  chamber,  as  recommended 
by  de  Vincentiis  and  Taylor,  and  extending  the  incision 
from  the  angle  of  the  chamber  into  the  sclera  at  the  level 
of  the  iris,  the  knife  must  not  be  inserted  too  deeply,  as, 
otherwise,  the  iris  afterward  gradually  slips  into  the  in- 
cision and  causes  a  corresponding  distortion  of  the  pupil. 

In  order  to  make  this  incision  correctly,  it  is  necessary 
to  apply  the  fixation-forceps  midway  between  the  wounds 
of  entrance  and  exit  (see  Plate  7).  This  is  an  important 
point,  as  it  enables  the  operator  to  make  this  incision  with 
such  certainty  and  precision  that  little  or  no  aqueous 
humor  escapes,  and,  if  necessary,  it  also  enables  him  to 


198  OPERATIONS  ON  THE  EYE. 

Fig.  73.— Small  knife,  after  Lang,  for  incising  the  cornea  preparatory 
to  the  introduction  of  the  blunt  knife,  shown  in  Fig.  74,  for  the  purpose 
of  separating  anterior  synechise. 

Fig.  75. — Steel  spatula,  after  Lang,  to  be  used  in  connection  with  a 
large  magnet  for  drawing  small  particles  of  iron  from  behind  the  iris. 

Fig.  76.— Curved  broad  needle  (keratome)  for  incising  the  cornea  (the 
needle  is  angular  rather  than  curved). 

Figs.  77  and  78.— Broad  needles  for  incising  the  cornea  for  a  narrow 
iridectomy,  etc. 

make  a  secondary  sclerotomy  immediately  after  the  first, 
which  enhances  the  effect. 

Preparatory  treatment  with  miotics  is  also  necessary  for 
sclerotomy,  to  guard  against  prolapse  of  the  iris  into  the 
wound. 

Under  the  name  of  posterior  sclerotomy  an  operation  for 
glaucoma  has  been  recommended.  It  consists  in  making 
a  short  incision  of  the  sclera  with  a  Gräfe  knife  farther 
backward,  in  the  equatorial  region  of  the  globe,  and  at 
the  same  time  incising  the  vitreous  to  a  considerable  depth. 
This  procedure  is  said  to  facilitate  a  subsequent  iridec- 
tomy or  to  enhance  the  effect  of  the  operation  when  it  is 
insufficient.  The  patient  is  told  to  look  toward  the  nasal 
side,  the  conjunctiva  is  seized  with  the  fixation- forceps 
near  the  horizontal  meridian  and  drawn  slightly  down- 
ward. With  a  Gräfe  knife,  the  back  of  which  is  directed 
toward  the  cornea,  the  sclera  is  then  punctured  in  the 
horizontal  meridian  at  least  5  mm.  behind  the  corneal 
margin,  and  the  knife  is  advanced  about  10  mm.  in  the 
direction  toward  the  center  of  the  globe.  As  it  is  with- 
drawn it  is  slightly  turned  on  its  axis,  so  as  to  make  the 
wound  gape  and  permit  some  of  the  fluid  to  escape.  In- 
fection is  guarded  against  by  displacing  or  drawing  the 
conjunctiva  to  one  side  as  the  knife  is  introduced  and  by 
observing  cleanliness.  Priestley  Smith  only  saw  hemor- 
rhage twice  after  this  method  of  sclerotomy  in  60  oper- 
ations. 

If,  in  from  ten  to  twenty  days  after  an  iridectomy,  the 
anterior  chamber  is  not  restored  and  malignant  glaucoma 
manifests  itself,  Ad.  Weber's  procedure  may  be  tried  as 


73 


74 


III 

75 


II 

76 


199 


200  OPERATIONS  ON  THE  EYE. 

Plate  7. 

Inferior  sclerotomy  in  a  case  in  which  iridectomy  had  previously  been 
performed  on  account  of  glaucoma. 

a  last  resort.  This  operation  is  performed  as  follows : 
During  a  posterior  sclerotomy,  such  as  has  just  been  de- 
scribed, with  an  incision  of  8-10  mm.  out  from  the  corneal 
margin,  and  while  the  wound  is  being  made  to  gape  by 
rotating  the  knife  through  J  of  the  circumference,  the 
operator  exerts  pressure  on  the  cornea  for  about  two 
minutes  by  means  of  the  upper  lid.  The  pressure  exerted 
must  be  slight  at  first  and  increased  gradually,  and  must 
act  in  a  direction  perpendicular  to  the  surface  of  the 
coloboma,  as  that  is  the  direction  toward  which  the  dislo- 
cation of  the  lens  is  usually  greatest.  The  object  of  this 
procedure  is  to  force  the  lens  back  when  it  has  prolapsed 
in  front  of  the  ciliary  processes.  When  the  greatest 
degree  of  pressure  has  been  obtained  it  should  be  kept  up 
for  from  one  to  one  and  one-half  minutes  in  order  to  give 
time  for  the  accumulation  of  aqueous  humor. 

(As  regards  resection  of  the  sympathetic,  which  has  been  recommended 
for  the  cure  of  glaucoma,  it  is  not  quite  clear  as  yet  whether  the  opera- 
tion has  any  great  value  or  is  even  permanent  in  its  effect,  and  whether 
the  benefit  derived  is  in  proportion  to  the  severity  of  the  operative  in- 
tervention ;  for  we  do  not  even  know  accurately  whether  it  may  not  do 
harm  in  some  other  direction. ) 

An  operation  very  much  like  the  above-described  pos- 
terior sclerotomy  is  puncture  of  the  sclera  as  recommended 
by  Deutschmann  for  the  cure  of  retinal  detachment.  A 
double  puncture  is  made  and  the  knife  is  carried  around 
the  periphery  instead  of  being  introduced  in  a  vertical 
direction.  The  procedure  is  most  adapted  to  cases  of 
some  standing,  in  which  the  detachment  has  already  gravi- 
tated downward.  After  the  instillation  of  atropin,  the 
patient  is  directed  to  look  up  and  a  bayonet-shaped  two- 
edged  knife  is  introduced  in  the  lower  fornix,  as  near  as 
possible  to  the  equator,  and  carried  transversely  across  the 
lowest  portion  of  the  globe,  so  that  the  knife  traverses  the 
subretinal  space,  the  retina,  and  the  preretinal  space,  and 


r 


J^ 


Ml 


I 


SCLEROTOMY.  201 

perforates  the  sclera  at  the  inner  and  lower  side  of  the 
globe,  but  does  not  perforate  the  conjunctiva.  The  knife 
i>  then  slightly  rotated  and  withdrawn,  so  as  to  permit 
subretinal  and  preretinal  fluid  to  escape.  Puncture  from 
below  upward  is  not  to  be  recommended.  If  necessary, 
the  procedure  may  be  repeated  several  times  at  short  in- 
tervals or,  in  some  cases,  after  an  interval  of  several 
months.  If  the  condition  still  does  not  improve,  the  in- 
jection of  vitreous  from  a  rabbit  should  be  tried.  The 
vitreous  is  taken  from  a  rabbit  about  three  months  old, 
and  thoroughly  stirred  up,  either  pure  or  with  the  addition 
of  saline  solution.  The  subretinal  fluid  having  been 
drained  off  by  means  of  the  above-described  incision,  the 
vitreous  material  is  injected  into  the  preretinal  space — I.  c, 
between  retina  and  vitreous.  As  the  rabbit  vitreous  is 
stirred,  gray  .  floeculi  form,  which  gradually  sink  to  the 
bottom.  The  more  of  these  floeculi  that  are  injected, 
with  strict  antiseptic  precautions,  of  course,  the  more 
severe  will  be  the  inflammatory  action.  This  procedure 
is  only  adapted  in  cases  in  which  all  other  hope  of  pre- 
serving the  eyesight  has  been  lost. 

L.  Müller  recently  recommended  an  operative  procedure  for  the 
cure  of  retinal  detachment.  It  consists  in  the  exri.<ion  of  a  myrüe- 
shaped  piece  of  the  sclera  in  the  equatorial  portion  of  the  temporal  half 
of  the  globe.  He  claims  that  this  reduces  the  volume  of  the  globe  and 
at  the  same  time  corrects  the  tension  of  the  choroid  and  retina  in  the 
1  on.tr.  myopic  globe.  The  effect  of  this  operation  is  said  to  be  that  the 
retina,  choroid  and  sclera  are  enabled  to  adapt  themselves  to  the  altered 
volume  of  the  vitreous.  The  outer  orbital  wall  having  been  tem- 
porarily resected,  after  Krönlein,  the  temporal  half  of  the  globe  is  ex- 
posed,  and  the  external  rectus  divided  after  it  has  been  secured  with 
two  ligatures.  With  a  small,  but  broad  and  very  sharp,  scalpel  a  short 
incision  is  then  made  in  the  most  superficial  f  of  the  sclera,  at  a  point 
about  1-2  mm.  behind  the  external  rectus,  and  then  a  second  one, 
parallel  to  the  first  and  to  the  same  depth,  at  a  point  8-10  mm.  farther 
back,  both  incisions  being  parallel  to  the  equator.  The  operator  must 
be  careful  to  keep  in  front  of  the  vortical  veins.  These  incisions  are 
then  prolonged  upward  and  downward  and  allowed  to  run  together 
above  and  below.  Sutures  are  then  introduced  at  intervals  of  3  mm. 
from  the  anterior  ed.^e  of  the  anterior  incision  to  the  posterior  edge  of 
the  posterior  incision,  and  temporarily  pushed  out  of  the  way  with 
their  ends  lying  up  and  down.     The  scleral  incisions  are  then  deepened 


202  OPERATIONS  ON  THE  EYE. 

Fig.  79. — Small  sharp  scoop. 

Fig.  80. — Small,  sharp  fenestrated  scoop. 

Fig.  81. — Small  sharp  scoop. 

Fig.  82. — Paracentesis-needle  with  stylet,  after  Desmarres. 

Fig.  83.— Cautery. 

until  suprachoroidal  serum  escapes,  after  which  the  entire  piece  of 
sclera  thus  marked  is  dissected  out  with  small  straight  scissors,  by  con- 
necting the  incisions  above  and  below.  The  choroid  must  not  be  in- 
jured. The  excised  piece  of  sclera  should  have  a  width  of  8-10  mm. 
and  a  length  (in  the  line  of  the  equator)  of  20  mm.  The  choroid, 
which  is  thus  exposed,  is  now  punctured  near  the  lower  angle  of  the 
wound,  to  allow  the  subretinal  serum  to  escape.  The  five  sutures  are 
then  tied  and  the  choroid  contracts  and  slips  under  the  sclera.  The 
external  rectus,  as  well  as  the  incision  in  the  orbital  periosteum,  are 
united,  the  bone  replaced,  and  the  outer  wound  closed. 

It  is  as  yet  too  early  to  determine  what  the  permanent  results  of  this 
procedure  will  prove  to  be. 


IV.   OPERATIONS  ON  THE   CORNEA,  SCLERA,   AND 
CONJUNCTIVA. 

1.  Among  the  operations  to  preserve  the  integrity  of  the 
cornea  the  most  important,  because  the  most  frequent,  is 
the  removal  of  foreign  bodies,  consisting  of  iron, 
stone,  etc.,  that  have  entered  the  tissues  of  the  membrane. 
Even  when  the  foreign  body  is  quite  superficial,  its  re- 
moval requires  some  knowledge  of  technic  as  well  as  of 
the  after-treatment;  for  it  is  not  enough  to  remove  the 
minute  foreign  body,  it  is  also  necessary  to  prevent  the 
slightest  inflammation  from  developing  at  the  site  of  the 
injury.  Secondary  infection  of  corneal  wounds  of  this 
kind  may  be  followed  by  obstinate  inflammatory  processes 
and  the  development  of  permanent  opacities  in  portions 
of  the  cornea ;  whereas,  with  proper  treatment  such  opaci- 
ties can  be  avoided. 

When  the  foreign  body  is  quite  superficial  an  attempt 
should  first  be  made  to  rub  it  off  with  a  sharp  probe, 
armed  with  cotton  and  moistened  with  a  bichlorid  solution 
of  1  :  5000.  If  this  attempt  fails,  and,  generally,  when 
the  foreign  body  is  more  deeply  situated,  it  must  be  dug 
out  with  a  spud.     This  is   usually  quite  difficult,  espe- 


79  80  81  82  83 


203 


204  OPERATIONS  ON  THE  EYE. 

cially  if  the  particle  of  iron  was  hot  when  it  entered  the 
eye,  as  it  is  then  usually  surrounded  by  a  brownish 
eschar,  which  must  also  be  removed.  Small  particles  of 
stone,  especially  such  as  are  acquired  by  working  with 
granite,  also,  as    a  rule,  present  considerable  difficulties, 


Fig.  84. 


particularly  if  the  illumination  is  insufficient  and  the 
patient  is  not  fairly  quiet.  The  whole  procedure  isT 
of  course,  greatly  facilitated  by  thorough  cocainization 
and,  if  there  is  great  irritation,  by  the  addition  of  adre- 
nalin as  well ;  and  above  all,  by  the  use  of  an  apparatus 


OPERATIONS  ON  CORSE  A,  SCLERA,  CONJUNCTIVA.    205 

designed  by  Sidler-Huguenin  (Fig.  84).  With  this  appa- 
ratus the  light  from  a  lamp,  which  is  placed  to  one  side, 
can  be  concentrated  on  the  operative  field  by  means  of  an 
illuminating  lens  (the  larger  of  the  two  lenses  in  the  fig- 
ure), which  is  attached  to  the  patient's  forehead  ;  while  at 
the  same  time  the  field  can  be  studied  with  a  magnifying 
glass,  so  that  the  foreign  body  can  be  removed  with  great 
accuracy. 

This  apparatus  will  be  found  to  give  excellent  results 
when  one  is  obliged  to  operate  on  foreign  bodies  without 
an  assistant.1 

Sharp  knives  or  discission-needles  are  better  than  the 
small  gouge  which  is  usually  recommended  for  removing 
foreign  bodies  from  the  tough  corneal  tissue,  because  the 
gouge  usually  lacks  a  sufficiently  sharp  edge,  and,  there- 
fore, crushes  and  injures  the  tissue.  If  a  surgeon's  hand 
is  so  unsteady  that  he  is  in  danger  of  perforating  the 
cornea  with  the  sharp  instruments  referred  to,  he  ought 
not,  under  any  circumstances,  to  undertake  operations  on 
the  eye. 

The  removal  of  a  foreign  body  consisting  of  some  mate- 
rial other  than  iron  from  the  deepest  layers  of  the  cornea 
may  be  a  very  difficult  operation,  requiring  great  coolness 
and  patience.  While  the  extraction  of  an  iron  spicule  is 
greatly  facilitated  by  the  use  of  the  large  magnet  (the 
small  magnet,  as  a  rule,  is  of  little  use,  because  the  for- 
eign body  is  usually  small,  and  the  magnet  does  not  exert 
sufficient  attraction),  a  small  particle  of  stone  or  copper 
simply  requires  patient  digging,  but  there  is  always  danger 
of  the  foreign  body  being  pushed  all  the  way  into  the 
anterior  chamber.  To  avoid  such  an  unpleasant  accident 
in  a  given  case  it  may  be  necessary  to  insert  a  narrow 
keratome  or  the  angular  broad  needle  (Fig.  76)  into  the 
anterior  chamber  and  hold  the  point  against  the  foreign 
body  in  order  to  prevent  its  slipping.  A  deeply  em- 
bedded splinter  of  this  kind  is  best  removed  with  a 
Gräfe  cataract-knife,  also,  of  course,  under  good  illumina- 
1  It  can  be  obtained  from  Goldschmid,  optician,  in  Zurich. 


206  OPERATIONS  ON  THE  EYE. 

tion.  The  operator  first  cautiously  cuts  down  on  the  for- 
eign body  and  then  works  away  with  the  point  of  the 
knife  and  tries  to  pick  out  the  splinter.  The  use  of  the 
forceps  should  be  avoided,  because  the  attempt  to  seize  a 
splinter  with  the  forceps,  as  a  rule,  results  in  thrusting  it 
farther  into  the  tissue. 

After  the  removal  of  any  foreign  body  from  the  cornea, 
even  when  it  is  very  superficial,  the  membrane  should  be 
examined  with  a  magnifying  lens  to  make  sure  that  the 
tissue  has  been  thoroughly  cleansed.  It  is  also  of  the 
greatest  importance  to  enforce  careful  after-treatment  in 
any  injury  by  a  foreign  body.  This  is  done  by  keeping 
up  the  occlusive  bandage  until  the  defect  is  found  to  be 
well  covered  with  epithelium. 

Special  care  is  required  in  removing  foreign  bodies  that 
have  lodged  in  the  depths  of  the  sclera,  and  can  not  be 
drawn  out  with  the  magnet,  because  they  do  not  consist 
of  iron.  They  must  be  carefully  pried  out  after  the  con- 
junctiva has  been  incised  and  drawn  apart  to  obtain  a 
cleaner  operative  field. 

If  for  any  reason  it  becomes  necessary  to  open  the  globe 
with  a  scleral  incision,  the  rule  is  to  place  the  incision  in 
a  meridian,  and  not  in  the  equator,  so  as  to  minimize  gap- 
ing and  injury  to  the  choroidal  vessels,  most  of  which 
are  in  the  anterior  half  and  run  parallel  to  the  meridian. 

2.  The  operation  of  puncturing  the  cornea  for  the 
purpose  of  removing  the  cataractous  masses,  which  has 
already  been  referred  to,  is  more  or  less  extensively  used 
for  other  purposes.  To  afford  escape  for  fluid,  such  as 
blood,  pus  or  mere  aqueous  humor,  from  the  anterior 
chamber,  a  small  puncture,  known  as  paracentesis,  suffices. 
For  this  purpose  Desniarres'  instrument  with  a  stop  (Fig. 
82)  is  used,  because  with  this  instrument  the  puncture, 
which  is  usually  placed  between  the  periphery  and  the 
center  of  the  cornea,  can  be  made  to  gape  by  means  of 
the  stylet,  with  which  the  peripheral  edge  of  the  wound 
is  pushed  back. 

Blood    in    the   anterior   chamber   may,  as   a    rule,    be 


OPERATIONS  ON  CORNEA,  SCLERA,  CONJUNCTIVA.    207 
allowed  to  become  absorbed.     There  are  cases,  however, 


in  which,  for  diagnostic  purposes,  for  example,  to  deter- 
mine the  presence  of  a  foreign  body,  the  removal  of  the 
blood  becomes  desirable.  There  are  also  cases  of  glioma 
of  the  retina  in  which  the  hemorrhage  takes  place  in  the 
anterior  chamber  and  obstructs  the  view  of  the  interior 
of  the  eye.  In  a  case  of  this  kind  I  once  succeeded,  by 
performing  this  trifling  operation,  in  determining  the 
presence  of  the  dangerous  tumor  at  once. 

Paracentesis  of  the  cornea  is  also  performed  in  cases  of 
deep  corneal  ulcers  that  threaten  to  rupture.  In  this  way 
an  extensive  ulceration  with  breaking  down  of  tissue  can 
be  guarded  against.  In  ulcus  serpens,  especially,  a  large 
incision  or  splitting  of  the  cornea  is  often  resorted  to. 
Saemisch's  operation  consists  in  dividing  the  entire  ulcer. 
The  eye  having  been  well  cocainized,  the  patient's  head  is 
held  between  the  hands  of  an  assistant,  and  the  globe 
steadied,  while  a  Gräfe  cataract-knife,  with  the  edge  pre- 
senting forward,  is  introduced  into  the  anterior  chamber 
behind  the  ulcer,  entering,  as  well  as  emerging  on  the  opposite 
side,  beyond 'the  edge  of  the  ulcer,  in  sound  tissue.  The 
incision  is  then  slowly  completed  by  drawing  the  knife 
forward.  The  last  instant  of  the  incision  is  usually  very 
painful,  because,  after  the  contents  of  the  chamber  have 
escaped,  the  inflamed  iris  comes  in  contact  with  the  cornea. 
The  direction  of  the  incision  should  be  such  that  the  most 
purulent  advancing  edge  of  the  ulcer  is  divided  in  two. 
The  incision  should  be  opened  up  every  day  with  a  blunt 
probe,  or  a  Weber  knife  for  opening  the  nasal  duct  (Fig. 
145),  until  the  ulcer  clears  up.  Both  at  the  first  incision 
and  at  the  subsequent  reopening  of  the  wound,  injury  of 
the  lens  must  be  carefully  guarded  against. 

According  to  Alf.  Gräfe  and  Meyhöfer,  an  incision  that 
does  not  divide  the  ulcer,  but  runs  at  a  tangent  to  the 
advancing  edge  of  the  ulcer,  as  a  kind  of  demarcation 
line  in  the  sound  tissue,  also  has  a  favorable  effect  on  the 
ulcer. 

The  incision  in  purulent  corneal  ulcers  evidently  acts 


208  OPERATIONS  ON  THE  EYE. 

in  the  same  way  as  the  incisions  made  by  surgeons  in 
cases  of  phlegmon,  they  relieve  the  tension  of  the  tissue 
and  assist  in  its  cleansing  by  providing  automatic  drain- 
age ;  for  a  current  is  set  up  in  the  tissue  toward  the  inci- 
sion, and  not  only  resists  the  advance  of  the  microbes, 
but  improves  the  nutrition.  If  there  is  any  objection  to 
treating  these  purulent  ulcers  of  the  cornea,  from  the 
beginning,  with  an  incision,  because  it  sometimes  causes 
anterior  synechia?  and  its  unpleasant  consequences,  the 
purulent  portions  may  be  scraped  out  with  a  sharp  scoop 
(Figs.  79-81)  and  dusted  with  iodoform,  or,  still  better, 
destroyed  by  heat — i.  e.,  by  means  of  the  small  galvano- 
cautery  (Fig.  83)  or  the  platinum  cautery. 

3.  The  Operation  for  Pterygium. — The  removal 
of  a  pterygium  may  be  deferred  until  the  advancing  apex 
of  the  fold  begins  to  show  thickening.  If  the  pterygium 
has  a  flat  point  and  is  not  very  vascular,  it  may  be  left  to 
itself;  but  when  it  has  already  advanced  to  the  pupillary 
region  it  is  best  to  remove  it  at  once.  Cauterization, 
which  is  often  desired  by  patients  who  are  afraid  of  the 
knife,  is  not  to  be  recommended  ;  a  better  operation  would 
be  to  ligate  the  membrane  off  with  silk  sutures,  which, 
however,  requires  a  longer  time  for  recovery  than  ablation 
or  transplanting. 

(a)  Ablation  after  Arlt. — After  the  eye  has  been  thor- 
oughly cocainized  and  thoroughly  cleansed,  the  pterygium 
is  seized  at  the  "  neck  " — that  is,  about  the  region  of  the 
corneoscleral  margin,  with  a  straight  conjunctival  forceps 
(like  the  instrument  illustrated  in  Fig.  88)  and  lifted  away 
from  the  globe.  In  this  way  it  is  quite  easy  to  separate 
the  part  that  lies  on  the  cornea  with  a  cataract-knife  or 
keratome.  The  membrane  must  be  removed  absolutely 
clean,  so  as  to  leave  no  part  of  the  "  head  "  remaining. 
The  membrane  ought,  in  a  sense,  to  be  peeled  off.  With 
a  straight  or  curved  scissors  the  body  of  the  pterygium  is 
then  excised  for  a  distance  of  6  to  8  mm.  by  means  of  two 
incisions,  converging  toward  the  caruncle.  The  triangular 
wound  in  the  conjunctiva  (base  of  the  triangle  at  the  cor- 


OPERATIONS  ON  CORNEA,  SCLERA,  CONJUNCTIVA.    209 

neal  margin)  is  then  united  by  means  of  a  suture.  When 
the  pterygium  is  large,  a  small  incision,  about  5  mm.  long, 
should  be  made  above  and  below,  in  the  edge  of  the  con- 
junctiva, at  a  tangent  to  the  corneal  border,  before  the 
wound  is  drawn  together,  as,  otherwise,  the  suture  causes 
too  great  tension.  That  part  of  the  sclera  near  the  cor- 
neal margin  which  corresponds  to  the  "  neck "  of  the 
pterygium  must  not  be  covered  with  conjunctiva. 

(b)  Transplantation. — This  operation  was  practised  by 
Desmarres  and,  according  to  his  method,  consists  not  in 
excising  the  pterygium,  but  in  merely  separating  it  from 
the  cornea  for  a  distance  of  from  5  to  6  mm.  The  tag  is 
then  displaced  obliquely  downward  and  sutured  into  the 
conjunctiva,  being  inserted  through  an  incision  made  for 
the  purpose  and  running  from  the  pterygium  obliquely 
downward.  This  incision  at  once  gapes,  the  separation 
being  greatest  near  the  pterygium,  and  thus  forms  a  suit- 
able triangular  wound  for  the  reception  of  the  tag. 

For  a  broad  pterygium,  Knapp  modified  this  method  as 
follows  :  After  the  head  of  the  pterygium,  if  it  is  hard, 
has  been  cut  off,  the  fold  is  divided  horizontally,  and  the 
two  tags  are  sutured  into  the  conjunctiva,  one  obliquely 
upward  and  the  other  obliquely  downward,  into  two  sim- 
ilar triangular  wounds.  The  original  site  of  the  ptery- 
gium is  then  covered  with  conjunctiva  by  undermining 
the  upper  and  lower  edges  of  the  membrane  at  the  corneal 
border  and  introducing  two  sutures,  which  suffice  to  cover 
the  defect  completely. 

Another  useful  method  is  McEeynolds'  modification  of 
Desmarres*  operation.  In  this  operation  the  pterygium  is 
also  displaced  obliquely  downward,  but  at  the  same  time 
it  is  pushed  under  the  conjunctiva.  The  pterygium  is 
dissected  away  from  the  cornea,  just  as  in  Arlt's  method  ; 
but  after  that  the  structure  is  merely  loosened  from  the 
sclera  and  undermined  at  its  lower  border  by  an  incision 
running  obliquely  downward  along  the  edge  of  the  fold 
— i.  e.f  in  the  case  of  nasal  ptervgoma,  the  direction  of 
the  incision  would  be  inward  and  downward.     The  con- 

14 


210  OPERATIONS  ON  THE  EYE. 

junctiva  is  then  undermined  below  and  outside  of  the 
incision,  and  a  suture  with  two  needles  is  passed  through 
the  head  of  the  pterygoma.  By  means  of  the  suture  the 
tip  of  the  pterygoma  is  then  drawn  obliquely  outward  and 
downward  under  the  conjunctiva,  the  two  needles  are 
brought  out  on  the  surface  of  the  conjunctiva,  and  the 
suture  is  tied.  No  incision  is  made  at  the  upper  border 
of  the  pterygium.  [This  is  the  most  satisfactory  ptery- 
gium operation. — Ed.] 

4.  The  utilisation  of  the  conjunctiva  to  cover 
defects  in  the  cornea,  either  by  transplanting  little 
flaps  without  pedicles  or  by  employing  a  flap  with  a  single 
or  double  pedicle — in  the  latter  case  a  bridge-like  flap — is 
a  procedure  that  was  first  attempted  by  Scholer  and  later 
perfected  by  Kuhnt.  The  method  is  of  use  to  afford  tem- 
porary protection  in  cases  of  slowly  healing  ulcers,  and  in 
cases  of  wounds  of  the  cornea  and  at  the  scleral  border. 
It  may  also  be  used  to  give  permanent  protection  to  parts 
that  have  a  low  resisting  power,  as,  for  example,  after  a 
prolapsed  iris  has  been  removed,  to  cover  distended  scars 
containing  iris  tissue  or  a  staphylomatous  bulging.  Ulcers 
must  first  be  well  curetted,  keratoceles  and  beginning 
staphylomata  must  be  freshened  up,  so  that  the  flap  will 
adhere,  either  by  carefully  removing  the  superficial  layer 
with  a  trephine  and  keratome,  or  by  scorching  superficially 
with  a  galvanocautery  and  scraping  away  the  eschar  after 
three  days. 

5.  Tattooing  of  the  cornea  with  Chinese  ink  is  an 
important  auxiliary  measure  and  is  employed  either  to 
obviate  the  blinding  effect  of  light,  when  diffused  through 
a  thin  corneal  scar  or  patch,  or,  for  cosmetic  reasons,  to 
give  a  dark  color  to  unsightly  white  spots  on  the  cornea, 
or,  finally,  in  certain  cases  of  cataract,  when  there  is  much 
disfigurement  on  account  of  the  whitish  sheen,  and  an 
operation  for  its  extraction  is  contra-indicated  by  retinal 
detachment  or  other  extensive  traumatic  changes  in  the 
eye.  In  these  cases  a  black  spot  is  tattooed  on  the  clear 
portion  of  the  cornea  to  simulate  a  pupil. 


OPERATIONS  ON  CORNEA,  SCLERA,  CONJUNCTIVA.    211 

So  far  I  have  not  had  occasion  to  tattoo  an  iris  on  the 
normal  cornea  of  an  albino  to  prevent  the  blinding  effect 
of  light,  but  should  not  hesitate  to  do  so  as  soon  as  I  had 
a  chance. 

Finally,  it  may  be  necessary  to  imitate  the  iris  when, 
for  example,  the  entire  cornea  is  gray  or  a  turbid  white. 
In  that  case  other  colors  besides  black  must  be  used.  In 
selecting  the  colors  only  those  should  be  taken  that  are 
not  soluble  and  do  not  irritate.  According  to  my  experi- 
ence such  a  color  is  cinnabar,  as  it  is  sold,  for  example, 
in  the  form  of  a  water  color  put  up  in  tubes,  which,  when 
mixed  with  Chinese  ink,  makes  a  very  useful  black.  To 
obtain  other  colors,  especially  blue,  Cofler  used  Japanese 
tattooing-colors,  for  which  he  sent  to  Tokio.  As  a  sub- 
stitute for  an  artificial  eye,  de  Wecker,  who  introduced 
tattooing  in  1870,  advised  its  use  on  an  iris  and  pupil  in 
shrunken  eyes  possessing  only  a  small  remainder  of 
cornea.  When  the  pupil  is  small,  tenotomy  is  first  per- 
formed on  the  four  straight  muscles  of  the  eye  in  order  to 
make  the  pupil  more  prominent  and  more  nearly  circular, 
de  Wecker  claims  to  have  had  very  good  results  with  this 
method. 

Cofler  also  recommends  tattooing  a  line  of  color  along 
the  edges  of  the  lids  to  make  up  for  the  disfiguring  of  eye- 
lashes. 

For  black,  which  is  the  color  most  frequently  used,  the 
best  Chinese  ink,  rubbed  up  in  a  glass  or  porcelain  dish 
until  the  consistence  is  fairly  thick,  should  be  used.  The 
ink  should  be  rubbed  up  in  a  few  drops  of  1:1000 
bichlorid  solution,  for  in  this  operation  also  infection 
should  be  carefully  guarded  against,  and  in  case  of  dacry- 
ostenosisor  catarrh,  appropriate  precautions  must  be  taken. 
I  saw  a  case  in  which  tattooing  (not  performed  by  myself) 
caused  panophthalmia.  By  observing  all  the  rules  of 
antisepsis,  I  have  never  seen  inflammation  after  a  tattoo- 
ing operation.  For  pricking  the  tissue  it  was  formerly 
customary  to  use  five  or  six  cambric  needles,  tied 
together  in  a  bundle,  so  as  to  make  a  number  of  punctures 


212  OPERATIONS  ON  THE  EYE. 

at  the  same  time ;  but  this  method  is  not  to  be  recom- 
mended. Hollow  needles  have  also  been  devised  (Bel- 
larminow),  and  an  instrument  that  is  filled  by  a  spring 
(Niedem),  and  with  which  the  color  can  be  introduced  at 
the  same  time  that  the  puncture  is  made,  thus  enabling 
the  surgeon  to  sketch  out  the  design  accurately.  If  neces- 
sary, however,  a  discission-needle  will  do.  The  pricks 
should  be  made  somewhat  obliquely.  A  small  quantity 
of  the  ink  may  be  first  painted  on  the  spot  that  is  to  be 
tattooed,  and  the  needle  thrust  through  it  when  the  prick- 
ing is  done,  the  color  being  afterward  rubbed  in  with  a 
smooth  spatula ;  or  the  pricking  may  be  done  first  and  the 
color  rubbed  in  afterward.  The  eye  should  be  cocainized  ; 
but  the  globe  must  not  be  held  with  the  forceps,  as  the 
point  where  the  forceps  is  applied  is  also  apt  to  become 
black.     The  globe  may  be  steadied  with  one  finger. 

Tattooing  must  never  be  performed  while  the  eye  is 
inflamed.  Ectatic  scars  are  not  suitable  for  this  pro- 
cedure. 

Sometimes  it  is  necessary  to  repeat  the  tattooing  after  a 
time,  probably  because  part  of  the  ink  has  been  carried 
off  by  wandering  cells,  or,  possibly,  has  disappeared  by 
exudation. 

6.  Removal  of  Dermoids. — Benign  but  disfiguring 
tumors  at  the  corneal  margin  not  infrequently  require 
operative  removal  (see  Atlas  and  Epitome  of  External  Dis- 
eases of  the  Eye,  Plate  11).  These  hard  tumors  are  known 
as  dermoids,  and  may  be  treated  in  the  same  way  as  a 
pterygium.  It  is  necessary  to  be  very  careful,  however, 
not  to  make  an  opening  in  the  cornea.  Even  when  extir- 
pation is  properly  performed,  there  remains  at  the  site  of 
the  tumor  a  pale  spot,  which  later  may  be  colored  to 
resemble  the  iris.  The  wound  in  the  conjunctiva,  from 
the  extirpation  of  the  tumor,  must  be  covered  by  under- 
mining the  membrane  and  drawing  it  together.  Subcon- 
junctival lipoma,  which  sometimes  accompanies  dermoid, 
especially  when  it  is  very  large,  requires  operative  inter- 
ference for  its  correction.     The  thickened  conjunctiva  is 


OPERATIOSS  OS  CORNEA,  SCLERA,  CONJUNCTIVA.    213 

excised  and  as  much  fat  removed  as  is  necessary  to  cause 
the  disappearance  of  the  structure  from  the  palpebral 
fissure. 

Carcinomatous  and  sarcomatous  growths,  which  pref- 
erably begin  at  the  limb  us  of  the  conjunctiva,  can  be 
locally  extirpated  only  when  they  are  quite  small.  They 
must  be  removed  as  well  as  possible  with  a  knife  and 
scissors,  and  the  site  cauterized  as  thoroughly  as  possible, 
with  the  Paquelin,  or  the  galvano-,  cautery,  without 
destroying  the  integrity  of  the  globe.  If  a  tumor  of  this 
kind  be  large,  enucleation  of  the  globe  is  indicated ;  but 
in  cases  of  suspicious-looking  nodules  a  piece  of  tissue 
should  be  excised  for  examination,  in  order  to  determine 
whether  the  growth  is  not  a  benign  papilloma  instead  of  a 
carcinoma. 

Polyps  and  papillomata  of  the  conjunctiva,  the  latter 
occurring  chiefly  at  the  inner  canth'us,  require  thorough 
extirpation,  after  which  the  wound  is  covered  with  con- 
junctiva. 

6.  A  staphyloma  of  the  cornea  may  call  for 
various  interventions,  depending  on  the  position  and  size 
of  the  growth.  In  the  case  of  partial  staphyloma  an 
iridectomy  to  relieve  pressure  often  acts  very  favorably. 
Excision  may,  however,  be  required,  the  wound-edges 
being  afterward  brought  together  witli  sutures  ;  or  a  con- 
junctival flap  may  be  drawn  over  the  defect.  In  one 
case  of  staphyloma,  about  5  cm.  in  diameter,  situated  at 
the  limbus  of  the  cornea,  and  wishing  to  have  as  firm  a 
scar  as  possible,  I  succeeded  fairly  well  by  dividing  the 
staphyloma  laterally  after  thoroughly  curetting  it.  The 
peripheral  portion  was  then  tucked  in  under  the  central 
portion,  which  formed  a  flap,  and  the  entire  wound  cov- 
ered in  with  conjunctiva  and  closed  with  sutures. 

In  cases  of  large,  or  even  total,  staphyloma  the  condi- 
tion may  be  improved  by  excising  some  part  of  the 
growth.  Snellen  recommends  for  this  purpose  a  proced- 
ure which  may  be  said  to  occupy  an  intermediate  posi- 
tion between  total  amputation,  as  done  by  Beer  and  Crit- 


214  OPERATIONS  ON  THE  EYE. 

chett,  and  Küchler' s  method  of  splitting  the  staphyloma, 
transversely  delivering  the  lens,  and  in  allowing  the 
wound  to  heal  under  an  occlusive  bandage.  He  excises 
a  comparatively  small  piece  from  the  bulging  mass  by 
passing  a  couching  needle  transversely  through  the  tip  of 
the  staphyloma,  and  then  with  a  Gräfe  cataract-knife 
makes  two  converging  incisions  from  without  inward,  one 
on  each  side  of  the  needle,  thus  excising  a  segment  which 
remains  transfixed  by  the  needle.  If  the  wound  is  found 
to  be  too  small  to  allow  the  lens  to  escape  after  its  capsule 
has  been  opened,  it  should  be  enlarged  to  the  right  and 
left  with  the  point  of  the  knife.  The  two  wound-surfaces 
are  readily  brought  into  opposition  by  slight  pressure,  such 
as  is  produced  by  an  occlusive  bandage. 

In  amputation  of  the  staphyloma  and  evacuation  of  the 
lens,  after  Beer,  who  subsequently  simply  allowed  the 
large  wound  to  heal  under  a  bandage,  de  Wecker  advises 
that  the  conjunctiva  should  first  be  incised  all  around  the 
cornea  and  undermined,  and  a  tobacco-pouch  suture  intro- 
duced, which  is  afterward  drawn  tight  over  the  wound. 
Suturing  the  sclera  alone,  after  Critchett,  when  some  of 
the  sutures  necessarily  go  through  the  ciliary  body  and, 
certainly,  through  the  interior  of  the  globe,  is  a  dangerous 
procedure  and  has  caused  sympathetic  ophthalmia.  If 
the  sclera  is  to  be  drawn  together  by  sutures,  it  must  be 
done  in  the  way  recommended  by  Knapp — that  is,  before 
amputation  is  performed  the  sutures  that  pass  through  the 
conjunctiva  and  sclera  must  be  introduced  in  such  a  way 
as  to  pass  only  through  the  most  superficial  layers  of  the 
sclera. 

In  the  case  of  a  very  large  staphyloma  or  one  that 
extends  into  the  region  of  the  ciliary  body  or  is  confined 
to  that  region,  enucleation  [or  Mules'  operation. — Ed.]  is 
the  proper  operation  if  the  growth  is  causing  any  disturb- 
ance. 


OPERATIONS  LX   THE  AXTEETOR   CHAMBER.     215 


V.  OPERATIONS   IN   THE   ANTERIOR   CHAMBER. 

In  addition  to  the  operations  affecting  the  anterior 
chamber,  which  have  already  been  referred  to — namely, 
iridectomy,  sclerotomy,  the  introduction  of  iodoform  and 
the  extirpation  of  small  tumors,  there  remain  to  be  con- 
sidered the  following  : 

1.  Separation  of  Anterior  Synechiae. — By  this 
procedure  a  distorted  pupil  may  be  made  to  assume  its 
proper  position,  and  distortion  of  the  iris,  particularly — 
which  is  sooner  or  later  followed  by  glaucoma — can  be 
corrected.  We  also  know  that  corneal  scars  containing 
inclusions  of  iris  are  dangerous,  on  account  of  the  possi- 
bility of  infection.  The  slightest  loss  of  tissue  in  such 
scars,  either  spontaneously  or  from  injury,  may  give  en- 
trance to  a  violent  infection,  often  in  the  form  of  a  rapid 
progressive  panophthalmia,  and  cause  the  destruction  of 
the  eye.  Attempts  were  formerly  made  to  separate  these 
adhesions  between  the  iris  and  cornea  by  means  of  an  iri- 
dectomy ;  but  this  is  often  a  very  difficult  procedure. 
Even  with  Gräfe's  knife  it  is  often  very  difficult,  if  not 
impossible,  to  separate  such  an  adhesion  if  it  is  broad. 
It  is  more  easily  done  with  the  two  needles  devised  by 
Lang  (Figs.  73  and  74),  one  of  which  is  used  merely  t<» 
make  a  small  incision  in  the  cornea,  while  the  other,  which 
is  blunt  at  the  point,  is  introduced  into  the  chamber  for 
the  purpose  of  separating  the  iris  from  the  cornea,  partly 
by  a  cutting,  and  partly  by  a  scraping,  movement.  It  is 
important  that  the  aqueous  humor  should  not  escape  dur- 
ing the  operation  ;  hence,  the  shaft  of  the  knife  should 
occlude  the  wound  in  the  same  way  as  has  been  explained 
in  connection  with  discission  (see  p.  115).  If  the  aqueous 
humor  escapes,  the  iris  comes  in  contact  with  the  cornea 
and  puts  an  end  to  the  free  and  correct  action  of  the  knife. 
It  i-,  therefore,  important  that  the  incision,  which  is  made 
with  the  first  knife,  or  needle,  should  not  be  too  close  to 
the  synechia?.  The  best  place  for  it  is  the  limbus  of  the 
sclera.     The  operation  is  not  altogether  easy.     It,  there- 


216  OPERATIONS  ON  THE  EYE. 

fore,  requires  thorough  cocainization  and  a  good  light.     A 
bandage  is  necessary  for  a  few  days  only. 

2.  The  separation  of  posterior  synechiae  also  was 
formerly  considered  important,  because  they  were  regarded 
as  possible  causes  of  secondary  attacks  of  iritis.  Blunt 
hooks  were  devised  for  the  operation.  It  is  an  unnecessary 
one,  however,  and,  if  the  synechiae  are  robust,  it  is  not 
without  danger,  on  account  of  possible  injury  to  the  cap- 
sule of  the  lens. 

3.  The  removal  of  foreign  bodies  from  the  anterior 
chamber  will  be  discussed  in  the  next  section. 

VI.  REMOVAL  OF  FOREIGN  BODIES  FROM  THE 
INTERIOR  OF  THE  EYE. 

For  the  sake  of  the  operative  technic  we  must  distin- 
guish between  foreign  bodies  of  iron  and  foreign  bodies 
of  some  other  material.  In  the  case  of  the  former  the 
magnet  can  be  used,  while  the  extraction  of  the  latter  is 
much  more  difficult,  and  the  operation  is  often  absolutely 
hopeless. 

Fortunately,  the  great  majority  of  foreign  bodies  that 
enter  the  interior  of  the  eye  consist  of  iron.  In  my  list 
of  cases  66  per  cent,  of  those  in  the  anterior  chamber, 
lens  and  iris,  and  75  per  cent,  of  those  in  the  vitreous, 
retina  and  choroid,  were  of  iron. 

(a)    Removal  of  Spicules   of   Iron   from   the  Eye   (Magnet 
Operation ) . 

As  it  is  usually  very  difficult  to  seize  a  foreign  body  in 
the  interior  of  the  eye  with  the  jaws  of  the  forceps ;  and 
when  the  foreign  body  is  surrounded  by  the  slippery  vit- 
reous the  attempt  is  practically  impossible,  the  employment 
of  the  magnet — at  first  only  for  the  purpose  of  grasping 
such  spicules — marks  a  great  advance  in  ophthalmology, 
for  which  we  are  indebted  to  McKeown  (1874).  For  his 
first  operations  he  used  a  stationary  magnet  8  in.  long 
and  pointed  at  each  end,  which  he  inserted  into  the  interior 


FOREIGN  BODIES  FROM  INTERIOR   OF  EYE.    217 

of  the  globe,  either  through  a  scleral  incision  or  through 
the  entrance  wound  made  by  the  foreign  body.  Griming 
also  used  a  similar  stationary  magnet.  Soon,  however, 
the  electromagnet  came  into  general  use — after  Hirsch- 
berg (1879),  Fröhlich,  Bradford,  Simeon  Snellen,  and 
others  had  designed  and  recommended  a  number  of  useful 
electromagnets.  A  powerful  magnet  can  be  made  by  tak- 
ing a  nucleus  of  soft  iron,  about  10  cm.  long  and  1  to  2 
cm.  thick,  wrapping  it  with  many  turns  of  copper  wire, 
and  surrounding  the  whole  by  a  moderately  strong  cur- 
rent from  a  large  immersion  battery.  One  end  of  the 
magnet  is  provided  with  a  thread  for  receiving  attach- 
ments of  varying  shape  and  thickness.  All  these  small 
magnets  were  and  still  are  constructed  on  this  principle. 
In  order  to  extract  a  spicule  from  the  interior  of  the  eye 
with  one  of  these  instruments,  it  is  necessary  to  bring  the 
point  of  the  probe,  which  is  attached  to  the  magnet,  in 
contact  with  the  foreign  body,  especially  if  the  latter  is 
more  or  less  tightly  wedged  or  lodged  in  the  tissues  (retina, 
etc.),  or  in  exudate  or  blood.  The  small  magnet  is  the 
best  instrument  for  seizing  foreign  bodies  of  this  kind, 
much  better  than  any  pair  of  forceps ;  but  at  best  the 
small  magnet  may  exert  a  very  slight  attractive  power  in 
a  non-infiltrated  vitreous  ;  that  is  to  say,  it  may  attract  a 
spicule  which  is  distant  from  2  to  3  mm.  from  its  point, 
but  only  when  it  is  quite  loose.  To  operate  successfully 
with  this  magnet  when  the  foreign  body  is  lodged  only 
moderately  tight,  it  is  necessary  to  know  approximately 
the  location,  in  order  to  bring  the  magnet  into  close  con- 
tact with  it.  As,  however,  in  many  cases — at  least  one- 
half  in  my  list — spicules  enter  the  globe,  injure  the  lens, 
and  very  frequently  produce  cataract  within  twelve  to 
twenty-four  hours,  thereby  making  it  impossible  to  see  the 
interior  of  the  eye,  and  as  hemorrhage  into  the  vitreous 
may  also  obscure  the  position  of  the  splinter,  the  use  of 
the  small  magnet  very  often  necessitates  uncertain  and 
haphazard  groping  about,  with  the  result  that  the  splinter 
not  infrequently  remains  lying  or  sticking  in  the  eye.     A 


218  OPERATIONS  ON  THE  EYE. 

still  greater  disadvantage  of  this  procedure  is  that,  as  a 
rule,  in  order  to  succeed  in  withdrawing  a  foreign  body 
from  the  depths  of  the  eye  (behind  the  iris  and  the  lens), 
a  rather  large  scleral  wound  (6  to  8  mm.  in  length)  is 
required,  or  the  entrance-wound  has  to  be  greatly  enlarged 
to  permit  the  introduction  of  the  magnet  into  the  interior 
of  the  eye.  The  entire  operation,  especially  when  the 
magnet  is  repeatedly  introduced  into  the  eye — as  often 
happens  when  the  surgeon  is  unsuccessful — constitutes  a 
very  serious  traumatism,  which  is  therefore  superadded  to 
the  injury  produced  by  the  foreign  body.  This  traumatism 
may  prove  fatal,  especially  for  the  vitreous,  which  is  not 
only  more  or  less  destroyed,  but  also  escapes  in  part,  or  at 
least  enters  the  wound,  and  is  in  danger  of  becoming  sec- 
ondarily infected.  During  the  operation  possible  infection 
of  the  interior  bulb  can  not  be  excluded,  because,  as  has 
been  pointed  out,  the  region  is  one  that  can  not  be  ren- 
dered absolutely  sterile. 

Furthermore,  probing  for  a  splinter  with  the  magnet  in 
a  more-or-less-recent  wound,  as  is  customarily  done,  is  a 
questionable  procedure ;  for  it  is  contrary  to  the  funda- 
mental principle  of  the  treatment  of  wounds  of  the  eye — 
which  is,  never  to  probe  a  wound  of  the  globe,  because  in 
so  doing  there  is  great  danger  of  carrying  into  the  inte- 
rior of  the  eye  any  pathogenic  germs  that  may  have 
already  settled  on  the  wound.  It  is  perfectly  obvious  that 
such  wounds  can  not  be  aseptic  before  the  probing  is  done. 

In  spite  of  these  objections  the  employment  of  the 
small  magnet  was  already  a  great  step  in  advance.  By 
its  help  many  eyes,  when  treated  cautiously,  were  saved, 
which  before  the  introduction  of  the  magnet  would  have 
required  enucleation  to  avoid  blindness.  Hirschberg,  in 
particular,  has  devoted  a  good  deal  of  work  to  the  devel- 
opment and  popularizing  of  the  method. 

An  important  improvement  was  added  to  the  procedure 
by  the  employment  of  freely  moving  magnetic  needles 
to  point  out  the  situation  of  the  iron  spicule  in  the  eye. 
The    method   had    not   been    in   use   long  before  it  was 


FOREIGN  BODIES  FROM  INTERIOR   OF  EYE.    219 

unpleasantly  brought  home  to  most  operators  who  used 
the  small  magnet  that  the  search  for  a  foreign  body  in  the 
interior  of  the  bulb  must  necessarily  be  carried  on  in  the 
dark  and  in  a  more  or  less  haphazard  fashion,  resulting 
in  a  comparative  stirring  up  of  the  contents.  Thus,  in 
1881,  Knapp  wrote  :  "Since  probing  the  vitreous  is  by 
no  means  a  harmless  undertaking,  we  must  exercise  all 
our  acumen  and  call  to  our  aid  every  means  at  our  com- 
mand to  determine  not  only  the  presence,  but  also  the 
exact  location,  of  a  piece  of  iron  to  the  vitreous/'  He 
thus  pointed  out  the  importance  of  the  investigations  pur- 
sued by  Pooley,  in  his  laboratory,  to  throw  light  on  the 
demonstration  and  localization  of  iron  particles  in  the  eye 
through  the  deviation  of  the  magnetic  needle.  In  the 
same  year  H.  Pagenstecher  published  his  experiment 
investigations,  which  likewise  prove  the  diagnostic  value 
of  the  magnetic  needle.  Fröhlich,  in  1882,  for  the  same 
purpose  recommended  a  magnetic  needle  suspended  by  a 
thread.  All  these  early  experiments,  however,  lack  that 
essential  requisite — an  apparatus  sufficiently  sensitive  to 
determine  the  location  of  the  foreign  body.  Gerard's 
instruments,  recommended  by  Gallemaerts  (1890),  and  the 
one  designed  by  Asmus  (1894)  were  the  first  that  pos- 
sessed sufficient  sensitiveness ;  the  manner  in  which  the 
needle  was  suspended  in  Asmus'  instrument,  particularly, 
rendered  it  practically  very  useful.  The  desired  degree 
of  sensitiveness  was  obtained  by  attaching  to  the  mag- 
netic needle  a  mirror,  which  reflects  the  light  of  a  lamp 
or  the  scale  of  a  telescope,  and  thus  makes  it  possible  to 
recognize  a  deviation  of  the  needle  that  would  not  be 
visible  to  the  naked  eye.  Asmus'  sideroscope,  which 
can  be  obtained  from  H.  Sitte,  Taschenstrasse  8,  Breslau, 
fulfils  the  requirements ;  but  it  is  so  sensitive  that  the 
needle  is  practically  never  at  rest  in  the  neighborhood  of 
an  electric  street  railway  or  a  steam  railroad.  Hirsch- 
berg, accordingly,  constructed  a  somewhat  less  sensitive 
"  iron  -searcher  "  with  a  similar  lamp  reflex,  which  moves 
up  and  down  on  a  scale  with  the  motion  of  the  needle. 


220  OPERATIONS  ON  THE  EYE. 

In  many  cases,  however,  the  deviation  of  the  needle  can 
be  recognized  with  the  naked  eye,  without  the  aid  of  a 
telescope  (Asm us). 

To  avoid  any  error  in  using  the  sideroscope,  the  patient 
should  be  stripped  to  the  waist,  and  even  then  iron  par- 
ticles under  the  scalp,  which  are  not  infrequently  found 
in  iron  workers,  may  become  a  source  of  error.  The  eye 
is  then  brought  near  that  end  of  the  magnetic  needle 
which  is  enclosed  in  a  glass  tube,  so  as  to  protect  it  fully 
against  any  current  of  air.  In  order  to  make  sure  that 
the  foreign  body  will  cause  a  deviation  of  the  needle,  it  is 
magnetized  by  applying  a  strong  magnet  to  the  eye, 
although  in  most  cases  it  is  already  magnetized.  The 
excursion  of  the  needle  will  be  proportional  to  the  size  of 
the  splinter,  and  inversely  proportional  to  the  distance. 
Different  portions  of  the  eye  are  brought  near  the  needle 
in  succession,  and  the  point  where  the  deviation  is  greatest 
corresponds  to  the  position  of  the  foreign  body.  With 
Asmus'  instrument  an  iron  particle  weighing  1  mg.  can 
be  detected  in  the  eye. 

That  very  desirable  quality  of  attraction,  however, 
namely,  that  of  acting  at  a  distance,  is  very  imperfectly 
possessed  by  the  small  magnet.  Magnetic  attraction,  by 
virtue  of  which,  according  to  the  old  legend,  the  mag- 
netic mountain  drew  all  the  nails  out  of  ships,  requires 
for  its  development  a  very  large  and  correspondingly  pow- 
erful magnet.  Although  some  of  the  earliest  ones,  like 
those  of  Mever  and  Minden  (1842),  Dixon  (1858),  Roth- 
mund (1873),  Hill  Griffith  (1882),  and  especially  Knies 
(1881),  who  used  a  very  strong  instrument,  were  capable 
of  attracting  foreign  bodies  at  some  distance,  the  ones 
named  above  were  not  utilized  to  any  extent  for  that  pur- 
pose, and  the  tech  nie  was  not  developed.  This  was  in 
part  due  to  the  fact  that  the  apparatus  which  they  used, 
owing  to  their  bulk,  were  not  suitable  for  operations  on 
the  eye.  In  1892  I  used  a  powerful  Ruhmkorif  magnet 
to  attract  into  the  anterior  chamber  an  iron  spicule  which 
had  been  lodged  for  three  weeks  in  the  posterior  capsule 


FOREIGN  BODIES  FROM  INTERIOR   OF  EYE.    221 

of  the  lens,  and  a  short  time  afterward  two  other  splinters 
in  the  vitreous.  I  then  followed  the  matter  up  and,  after 
studying  the  different  varieties  of  large  magnets  in  our 
physical  laboratories,  constructed  with  the  help  of  our 
physicist,  Prof.  Kleiner,  a  giant  magnet  (Figs.  85  and 
86),  which  we  adapted  as  well  as  we  could  to  operative 
purposes.  This  magnet  possessed  the  following  advan- 
tages :  1.  It  enabled  the  operator  to  obtain  a  good  view 
of  the  operative  field.  2.  It  possessed  the  necessary 
power  to  attract  the  smallest  splinters  from  the  deeper 
portions  of  the  eye  to  the  anterior  surface.  3.  It  could 
be  instantly  brought  into  action  or  rendered  passive  by 
opening  and  closing  the  electric  current.  It  was  soon 
found,  however,  that  it  is  not  enough,  when  an  eye  con- 
tains a  splinter,  merely  to  bring  it  within  the  influence 
of  the  large  magnet ;  there  must  also  be  some  provision 
for  properly  directing  the  enormous  power  of  which  the 
magnet  is  capable.  I  discovered  that  a  foreign  body 
which  has  entered  the  vitreous  does  not,  as  I  had  first 
thought,  when  magnetically  attracted,  simply  return  by 
its  way  of  entrance.  On  the  contrary,  it  may,  for  exam- 
ple, be  drawn  forward  from  the  retina  on  the  posterior 
pole  of  the  eye,  through  the  vitreous,  in  any  direction  ; 
and  with  great  rapidity  if  weighing  20  mg.  or  more,  and 
slowly  if  smaller.  I  demonstrated  by  experiments  per- 
formed on  a  pig's  eye  that  a  foreign  body  is  drawn  toward 
the  point  of  the  magnet,  and,  if  the  point  happens  to  be 
opposite  the  cornea,  the  intrusive  substance  rapidly  slips 
around  the  lens  by  the  shortest  route,  and,  puncturing  the 
zonule  of  Zinn,  appears  behind  the  iris  and  pushes  the 
curtain  forward. 

If  the  pupil  is  not  very  much  contracted  the  spicule 
may  pass  directly  through  it  and  appear  in  the  anterior 
chamber,  thus  making  it  appear  as  if  it  had  passed 
directly  through  the  lens  or  through  the  iris.  It  is  prob- 
able, however,  that  a  foreign  body  never  passes  through 
the  lens  in  its  exit  from  the  eye,  even  if  the  lens  was 
injured  at  the  time  of  the  accident ;  nor  do  I  believe  that 


Fig.  85.— Showing  the  use  of  the  large  magnet  in  extracting  an  iron  spicule 
from  the  eye. 

222 


Fig.  86-Showing  the  use  of  the  large  magnet  in  extracting  an  iron  spicule 

from  the  eye. 

223 


224  OPERATIONS  ON  THE  EYE. 

it  is  likely  to  make  its  way  through  the  iris,  except  in 
very  rare  cases.  It  may  possibly  pass  through  the  wound 
of  entrance  in  the  iris  or,  if  it  is  a  pointed  object  and  the 
iris  is  well  stretched — that  is,  the  pupil  is  contracted — it 
may  penetrate  the  iris  near  its  ciliary  attachment ;  but 
such  accidents  are  exceptional.  As  a  rule,  the  foreign 
body  goes  around  the  lens  and  slips  behind  the  iris,  so 
that,  if  it  has  lodged  at  some  unknown  point  in  the  pos- 
terior portion  of  the  vitreous,  there  is  no  means  of  know- 
ing where  it  will  appear  behind  the  iris  when  the  point 
of  the  magnet  is  held  immediately  in  front  of  the  center 
of  the  cornea.  If  located  in  the  lower  part  of  the  vitreous 
before  the  magnetic  attraction  begins  to  exert  its  influ- 
ence, it  is  usually  drawn  to  a  point  behind  the  posterior 
portion  of  the  iris.  But  if  the  point  of  the  magnet,  at  the 
moment  of  attraction,  were  held  opposite  the  upper  por- 
tion of  the  cornea,  the  substance  might  slip  around  the 
lens  and  appear  behind  the  upper  portion  of  the  iris. 

In  order  that  a  foreign  body  that  has  lodged  behind  the 
iris  may  be  drawn  through  the  pupil  into  the  anterior 
chamber,  certain  conditions  are  desirable  :  It  should  not 
penetrate  the  iris  as  it  is  withdrawn  ;  it  should  be  as  free  as 
possible  from  sharp  projections  and  barbs  ;  and  the  sphinc- 
ter should  be  previously  paralyzed  in  order  to  dilate  the 
pupil.  One  of  these  conditions  is,  of  course,  beyond  our 
control.  To  prevent  the  foreign  body  from  penetrating 
the  iris,  the  electric  current  is  opened  and  the  patient's 
head  pushed  away  from  the  magnet  at  the  instant  the  iris 
begins  to  bulge.  As  a  rule,  the  patient,  of  his  own  accord, 
immediately  jerks  his  head  back.  He  is  then  requested 
to  rotate  the  eye  toward  the  side  where  the  foreign  particle 
lies  behind  the  iris — as,  for  example,  downward  if  it  is 
behind  the  lower  portion  of  the  iris — so  that  it  is  drawn 
obliquely  through  the  pupil  into  the  anterior  chamber. 

It  is  also  found,  after  a  short  experience  with  the  method, 
that  even  a  very  powerful  magnet  is  hardly  able  to  with- 
draw a  splinter  that  has  lodged  in  the  interior  of  the  globe 
or  has  become  surrounded  with  exudate,   blood,  etc.,  it 


FOREIGN  BODIES  FROM  INTERIOR   OF  EYE.    2'1'i 

being  firmly  held,  particularly  if  it  has  entered  the  poste- 
rior wall  of  the  globe.  In  such  cases  the  best  results  will 
be  obtained  by  drawing  out  the  spicule  a  little  at  a  time, 
by  rapidly  opening  and  closing  the  current.  It  is  also 
well  in  such  cases  to  loosen  up  the  spicule  by  bringing  the 
point  of  the  magnet  nearer,  as,  for  example,  drawing  it 
from  the  posterior  pole  toward  the  equator  without,  how- 
ever, allowing  the  intruder  to  become  firmly  lodged  in  its 
new  position.  From  the  equator  the  spicule  is  then  drawn 
toward  the  anterior  portion  of  the  eye.  The  maneuver 
requires  a  special  kind  of  magnet ;  for  it  is  necessary  to 
be  able  to  attract  the  splinter  as  accurately  as  possible 
toward  the  desired  point  on  the  equator,  and  it  must  also 
be  feasible  to  open  the  current  at  once  as  soon  as  the 
extraneous  substance  has  announced  its  presence  at  the 
equator  by  causing  pain. 

It  should  therefore  be  practicable,  by  means  of  the  mag- 
net, to  lay  out  the  track  which  it  is  to  follow  as  it  is 
extracted  from  the  eye,  and  to  prevent  as  much  as  possible, 
both  when  drawn  forward  and  to  one  side  (equator),  its 
getting  into  the  ciliary  body.  For  I  soon  ascertained  that 
it  is  quite  difficult,  when  an  iron  spicule  has  lodged  in  the 
ciliary  body  (either  primarily,  at  the  time  of  its  entrance 
into  the  globe,  or  secondarily,  during  the  attempt  to  with- 
draw it),  to  extract  it  by  means  of  magnetic  attraction. 
This  is  probably  owing  to  the  fact  that  the  region  is  full 
of  folds  and  inequalities,  which  make  it  very  difficult  for 
the  splinter  to  move. 

Hence,  in  such  cases  our  task  will  be  to  concentrate  the 
action  of  the  magnet,  so  that  the  foreign  body  is  first 
drawn  backward  toward  the  equator  and  then  forward  to 
the  anterior  portion  of  the  eye.  It  is  better  to  draw  it 
behind  the  iris  of  the  opposite  side,  and  prevent  it  from 
again  slipping  into  the  ciliary  body,  which  lies  immedi- 
ately in  front  of  it. 

It  was  also  found  that  in  a  fresh  wound  the  splinter 
could  at  once  be  drawn  out  from  the  anterior  chamber  if 
it  had  entered  through  the  cornea.     The  last  step,  when  it 

15 


226  OPERATIONS  ON  THE  EYE. 

is  possible  at  all,  requires  good  eyesight  and  a  strong 
light — in  other  words,  the  operative  field  must  be  per- 
fectly accessible.  The  operator  must  be  able  to  see  accu- 
rately what  is  going  on  if  he  hopes  to  bring  the  splinter, 
which  is  freely  movable  in  the  anterior  chamber  and  can 
be  drawn  to  any  desired  point  on  the  cornea  with  the 
magnet,  exactly  opposite  the  wound  of  entrance,  so  that  it 
will  pass  out  through  the  same  opening.  Since  an  oblong 
spicule  always  approaches  the  magnet  in  a  longitudinal 
direction  (head  on),  it  is  often  possible  to  remove  it  in  this 
way  through  the  en  trance- wound  in  the  cornea  if  it  is  not 
too  small.  It  is  said  that  in  a  similar  way  a  splinter  in 
the  anterior  chamber  can  be  extracted  through  a  small 
incision  in  the  cornea. 

All  the  above-described  requirements,  which  are  fully 
possessed  by  the  large  or  giant  magnet,  necessitated  as 
great  an  attractive  power  as  possible,  and,  therefore,  a 
large  mass  of  iron  and  a  correspondingly  strong  electric 
current  were  necessary.  At  the  same  time  we  had  to 
avoid  making  the  implement  too  unwieldy  in  other  re- 
spects. For,  although  the  instrument  is  large,  a  certain 
ease  in  handling  it  is  absolutely  indispensable,  because  it 
must  be  possible  to  concentrate  the  great  magnetic  power 
on  any  desired  or  given  point  and  allow  it  to  act  on  the 
eye  rapidly  from  various  directions. 

It  would  be  wrong  not  to  utilize  the  great  mobility  of 
the  patient's  head  and  eye ;  for  it  is  hardly  possible  by 
any  ingenuity,  in  suspending  or  balancing  so  large  a  mass 
of  iron  as  is  required  for  this  purpose,  to  give  it  quite  all 
the  desired  mobility.  These  considerations  ultimately  led 
me  to  construct  the  model  shown  in  Figs.  85  and  86, 
which  has  proved  its  usefulness  in  nearly  200  operations 
performed  with  it  in  my  clinic,  and  which  I  still  consider 
the  best,  even  in  comparison  with  other  large  magnets  that 
have  been  designed  more  recently. 

I  lay  great  stress  on  the  value  of  having  the  magnet  in 
a  horizontal  position  and  allowing  the  patient  free  move- 
ment of  the  head  (without  chin  support,  etc.). 


FOREIGN  BODIES  FROM  INTERIOR   OF  EYE.    227 

Some  operators  have  suspended  the  giant  magnet  vertically,  with 
the  patient  lying  on  his  back  underneath.  I  consider  this  a  faulty 
method  because  it  sacrifices  the  free  mobility  of  the  patient's  head.  If 
the  patient  is  seated  in  front  of  the  magnet,  as  shown  in  the  two  fig- 
ures (85,86),  his  head  can  be  moved  away  from  the  magnet  much 
more  easily  than  when  he  is  lying  underneath  the  instrument,  and,  as 
we  shall  see,  the  distance  of  the  eye  from  the  magnet,  which  may  have 
to  be  changed  very  suddenly,  plays  a  very  important  part  in  magnet 
operations. 

A  nucleus  of  soft  iron,  10  cm.  thick  and  60  cm.  long, 
and  weighing  30  kg.,  is  surrounded  by  a  massive  cover- 
ing of  copper  wire,  through  which  a  constant  current  of 
70  to  100  volts  and  20  to  30  amperes  is  passed.  The 
instrument  can  also  be  controlled  for  a  tension  varying 
from  30  to  500  volts.  There  is  no  need  of  a  rheostat  to 
regulate  the  strength  of  the  current.  The  simplest  way 
to  reduce  the  power  of  the  magnet  is  by  removing  the 
eye  farther  away  from  the  pole  or  by  lengthening  the 
latter  by  using  a  longer  attachment.  The  shorter  the 
point  of  the  pole,  the  greater  the  attraction.  Although  it 
possesses  a  greater  attractive  power,  too  blunt  a  pole  is 
unsuitable,  because  it  obstructs  the  view  of  the  operative 
field  too  much.  For  the  same  reason  the  wire  wrapping 
should  diminish  in  thickness  as  it  approaches  the  point 
of  the  pole.  One  pole  is  somewhat  rounded,  while  the 
other  ends  in  a  sharp  point.  The  magnet  can  be  rotated 
around  a  vertical  axis  so  that  either  end,  the  blunt  as  well 
as  the  sharp,  can  be  brought  opposite  the  eye.  Both  ends 
can  be  unscrewed  and  the  power  of  the  pole  thereby 
increased.  It  is  most  important,  in  my  opinion,  that  the 
magnet  should  be  so  constructed  as  to  permit  the  operator 
to  close  the  current  with  the  foot,  as  shown  in  the  figures 
(85  and  86),  and  leave  both  hands  free  to  manage  the 
patient's  head  and  eyelids.  As  the  current  is  closed  only 
by  depressing  the  pedal  on  one  side  or  the  other,  it  is 
passed  through  the  mechanism  only  as  long  as  it  is  neces- 
sary and  there  is  no  danger  of  the  wrapping  becoming 
heated  and  the  instrument  being  ruined  by  the  current 
being  inadvertently  kept  up  too  long. 


228  OPERATIONS  ON  THE  EYE. 

Another  absolute  necessity  is  good  illumination  of  the 
operative  field,  either  with  the  electric  lamp  or  with  the 
light  from  a  large  gas  flame,  concentrated  by  means  of  a 
large  convex  lens. 

Whether  the  giant  magnets  recently  constructed  by 
Volkmann  and  Edelmann-Schlösser  after  a  different  type 
will  prove  practically  useful  remains  to  be  seen.  [Hirsch- 
berg has  recently  constructed  a  new  giant  magnet. — Ed.] 
In  both  of  these  devices  it  seems  to  me  that,  as  the  pole 
projects  only  a  very  short  distance  beyond  the  end  sur- 
face, a  maximum  of  power  has  been  gained  at  the  expense 
of  a  good  view  of  the  operative  field. 

The  indication  for  the  employment  of  the  giant  magnet 
is  obtained  from  a  preliminary  accurate  examination  and 
the  resulting  diagnosis  :  a  splinter  in  the  eye.  In  case  of 
doubt  the  diagnosis  should  be  adhered  to  until  every 
means  of  examination  has  been  exhausted  and  it  has  been 
shown  that  the  eyeball  does  not  contain  a  splinter.  The 
large  magnet,  of  course,  also  represents  one  method  of 
examination,  and  very  often  makes  possible  a  correct 
diagnosis  at  the  same  time  that  it  furnishes  the  best 
means  of  treatment.  In  any  case,  however,  if  the  patient's 
statements  contain  the  slightest  hint  of  the  fact,  it  should 
be  ascertained  by  minute  inspection  of  the  eye  under 
lateral  illumination  and,  if  necessary,  with  a  magnifying 
lens  whether  or  not  a  foreign  body  has"  entered  the  inte- 
rior of  the  eye.  As  the  great  majority  of  foreign  bodies 
enter  through  the  cornea  and  the  adjacent  zone  of  the 
sclera,  and  many  of  them  later  pass  through  the  iris  or 
the  lens,  or  both,  an  examination  by  lateral  illumination 
in  many  cases  reveals  not  only  the  point  of  entrance  but 
also  the  subsequent  course  of  the  foreign  body.  The 
entrance  wound  in  the  cornea  often  consists  of  a  short 
straight,  or  sometimes  curved,  gray  line,  and  on  close 
inspection  a  second  line  will  usually  be  seen  running  par- 
allel to  it,  which  is  the  wound  in  Descemet's  membrane. 
In  cases  of  recent  injury  by  a  foreign  body  the  demon- 
stration of  a  wound  in  the  capsule  of  the  lens,  which  is 


FOREIGN  BODIES  FROM  INTERIOR   OF  EYE.    229 

recognized  by  a  grayish  opacity  with  a  dark  cleft,  often 
indicates  that  the  intruding  substance  has  penetrated  as 
far  as  the  vitreous.  Careful  examination  with  the  oph- 
thalmoscope may  afford  very  useful  additional  informa- 
tion, either  by  enabling  the  examiner  to  see  the  foreign 
body  in  the  vitreous  or  in  the  retina,  or  by  revealing  the 
place  where  it  has  struck  against  the  eyeground  (see  my 
Atlas  of  Ophthalmoscopy,  Fig.  51 ).  For  it  sometimes  strikes 
against  the  eyeground  and  then  rebounds  downward  and 
forward.  Air  bubbles  in  the  vitreous  indicate  the  pres- 
ence of  a  splinter,  but  are  not  absolutely  pathognomonic,  as 
they  also  occur  after  non-penetrating  wounds  of  the  eye. 

The  question  whether  the  injury  has  caused  a  penetrat- 
ing or  a  non-penetrating  wound  of  the  eye — the  latter 
case,  for  example,  a  long  splinter  may  have  injured  the 
eye  without  entering  it — can  sometimes  be  determined  by 
noting  the  relation  between  the  entrance  wound  and  the 
depth  of  the  wound  canal.  When  cataract  is  present, 
however,  the  question  can  often  be  decided  in  no  other 
way  than  by  means  of  the  magnetic  needle,  the  Röntgen 
rays,  or  the  immediate  use  of  the  large  magnet  to  draw 
the  foreign  body  to  the  surface.  The  foreign  substance  in 
such  cases  is  usually  a  large  one.  In  cases  of  non-pene- 
trating wounds  the  iris  is  more  likely  to  be  prolapsed  into 
the  wound  than  is  the  case  when  there  is  an  intrusion  in 
the  depths  of  the  eyeball  (Griming).  According  to  my 
observation  there  is  one  exception  to  this  rule — that  is, 
when  a  large  splinter  has  penetrated  the  deeper  portions 
of  the  eye.  In  such  cases  the  iris  may  be  thrown  into 
the  wound,  but,  as  a  rule,  the  prolapse  involves  only  a 
small  portion  of  the  curtain. 

Röntgen  rays  are  indispensable  for  making  an  accurate 
diagnosis  if  it  be  found  that  both  the  magnetic  needle  and 
the  giant  magnet  remain  passive,  and  it  therefore  seems 
probable  that  a  foreign  body  consisting  of  some  other 
metal  or  of  stone  has  entered  the  eye. 

If  the  magnetic  needle  indicates  iron  and  the  magnet 
fails  to  act,  it  may  be  possible  to  show  by  means  of  radiog- 


230  OPERATIONS  ON  THE  EYE. 

raphy  that  the  substance  has  passed  through  the  poste- 
rior wall  of  the  globe  and  thus  escaped  from  the  eye.  A 
good  Röntgen-ray  picture  may  also  be  of  use  to  demon- 
strate the  presence  of  a  splinter  in  the  region  of  the  ciliary 
body.  Such  a  picture  will  show  a  foreign  body  of  0.5  to 
1  mm.  in  diameter,  unless  it  consists  of  glass  or  wood,  which 
throws  no  shadow  at  all,  while  stone  makes  a  very  light 
shadow. 

In  recent  cases  of  intruding  objects,  especially  when  it 
may  be  suspected  that  the  article  has  led  to  a  complicat- 
ing infection  (soiled  iron,  especially  splinter  from  a  hoe), 
and  the  indication  is  to  extract  the  material  as  rapidly  as 
possible,  it  would  be  a  bad  practice  to  waste  time  by  mak- 
ing a  Röntgen-ray  picture  or  using  the  sideroscope.  It  is 
better  in  such  cases  to  use  a  magnet-test  at  once,  instead 
of  the  other  two  methods ;  for  the  history  and  the  size  of 
the  entrance  wound  give  us  information  of  some  value  in 
regard  to  the  dimensions  of  an  iron  spicule  in  the  eye.  If 
such  information  is  not  obtained,  the  excursion  of  the 
magnetic  needle  may,  it  is  true,  afford  valuable  informa- 
tion. The  question  of  the  size  is  important,  because,  if 
the  spicule  is  large,  it  must  be  drawn  forward  very  slowly 
— that  is,  the  eye  must  first  be  placed  some  distance  away 
from  the  magnet  and  gradually  brought  nearer.  Again, 
if  the  splinter  is  large,  it  may  be  necessary  to  extract  it 
laterally  through  the  sclera,  instead  of  through  the  ante- 
rior chamber,  bringing  it  out  either  through  the  entrance 
wound,  if  it  is  situated  in  that  region,  or  through  an 
incision  made  for  the  purpose.  Whenever  possible,  how- 
ever, the  foreign  body  should  be  extracted  through  the 
anterior  chamber,  because  by  doing  so  any  further  injury  to 
the  vitreous — which  is  unavoidable  wrhen  the  foreign  body 
is  extracted  through  the  side  with  or  without  operative 
enlargement  of  the  entrance  wound — is  thereby  saved. 
Even  a  fairly  large  splinter  (3  to  6  mm.)  can  be  drawn 
around  the  lens  without  injuring  the  structure.  The 
majority  of  splinters,  however,  are  smaller  than  the  size 
just    mentioned,    and    in    half   of  the    cases   the  lens  is 


FOREIGN  BODIES  FROM  INTERIOR  OF  EYE.    231 

already  injured.  It  is  only  by  extracting  a  foreign  body 
through  the  anterior  chamber  that  the  possibilities  of 
sparing  the  eye,  which  are  afforded  by  the  use  of  the 
large  magnet,  are  utilized  to  their  fullest  extent. 

To  interrogate  the  sideroscope  about  the  location  of  the 
splinter  in  the  eye  in  every  case  would  also  lead  to  unnec- 
essary waste  of  time,  and  when  the  large  magnet  is  used, 
the  sideroscope  may  be  dispensed  with,  as  the  magnet 
itself  finds  out  the  location  of  the  particle. 

The  operation,  as  a  rule,  is  performed  about  as  follows  : 
Atropin  and  cocain  and,  if  necessary,  adrenalin  having 
been  instilled  into  the  eye,  the  surrounding  parts  are 
thoroughly  cleansed,  and  the  conjunctival  sac,  which  is 
often  polluted  in  the  case  of  workmen,  is  flushed  out,  and 
the  patient  made  to  sit  in  front  of  the  magnet  with  his 
arms  well  braced.  Watches  should  first  be  removed,  as 
the  steel  parts  of  the  mechanism  are  ruined  by  becoming 
magnetized.  The  operator  assumes  one  of  the  two  posi- 
tions shown  in  the  figures  (85  and  86).  If  the  patient  is 
nervous  and  constantly  draws  his  head  back  from  the 
instrument,  from  fear,  the  operator  should  stand  behind 
him.  Either  position  permits  the  operative  field  to  be 
well  kept  in  view  and  the  lids  fixed  with  the  fingers.  As 
a  rule,  it  is  not  necessary  to  fix  the  globe  during  the  opera- 
tion, but  in  any  case  the  forceps  that  is  used  should  not 
be  of  iron.  If  the  operator  wears  spectacles  with  steel 
rims,  he  must  be  careful  not  to  get  too  near  the  magnet, 
as  it  might  snatch  the  spectacles  from  his  nose  at  the 
crucial  moment.  For  the  same  reason  lamps  that  contain 
any  iron  must  be  kept  at  a  distance  of  10  to  20  cm. 

The  most  important  rule  for  the  great  majority  of  cases 
— that  is,  all  those  in  which  a  small  to  a  medium-sized 
splinter  is  present — is  to  begin  by  placing  the  eye  with 
the  center  of  the  cornea  exactly  opposite  the  pole  of  the 
magnet. 

If  the  presence  of  a  large  splinter  in  the  eye  is  sus- 
pected, the  pole  of  the  magnet  should  first  be  allowed  to 
act   at   some   distance   from    the  eye,  the  distance  being 


232  OPERATIONS  ON  THE  EYE. 

directly  proportional  to  the  probable  size  of  the  splinter. 
If  the  results  of  the  preliminary  examination  indicate  the 
probable  presence  of  a  small  splinter,  the  cornea  should 
be  placed  close  to  the  blunt  pole  of  the  magnet,  and  the 
patient  told  to  look  in  that  direction.  Often  the  first 
closure  of  the  current,  which  is  accompanied  by  a  slight 
cry  of  pain  and  retraction  of  the  head,  brings  the  foreign 
body  behind  the  iris.  Sometimes  pain  is  the  only  result, 
in  which  case  the  current  must  be  repeatedly  opened  and 
closed  to  continue  the  attraction,  the  pole  of  the  magnet 
being  at  first  kept  constantly  opposite  the  center  of  the 
cornea.  If  this  fails  to  produce  any  bulging  of  the  iris, 
more  lateral  portions  of  the  cornea  are  successively 
brought  opposite  the  pole  ;  but  the  region  of  the  ciliary 
body  must  be  scrupulously  avoided.  If  this  fails  to 
attract  the  foreign  body,  an  attempt  should  be  made,  as 
above  described,  to  draw  it  laterally  toward  the  equator 
of  the  globe.  From  time  to  time,  however,  the  magnet 
should  be  brought  opposite  the  center  of  the  cornea. 

Attempts  to  draw  the  splinter  into  the  anterior  chamber 
must  not  be  given  up  too  soon,  for  its  removal  may  require 
a  good  deal  of  time  and  frequent  jerks  with  the  maximum 
of  current  permissible — as,  for  example,  when  the  foreign 
body  is  surrounded  by  a  small  mass  of  exudate  that  causes 
it  to  adhere  to  the  retina.  This  slow  process  of  loosening 
up  the  foreign  body  can  sometimes  be  observed  with  the 
ophthalmoscope.  I  have  seen  cases  in  which  it  wras  suc- 
cessfully extracted  only  after  attempts  to  draw  it  forward 
had  been  repeated  several  days  in  succession. 

In  difficult  cases  of  this  kind  the  attractive  power  of 
the  magnet  may  be  increased  by  unscrewing  the  point. 
Whenever  I  found  it  impossible  to  dislodge  a  splinter  em- 
bedded in  the  retina,  which  I  could  see  with  the  ophthal- 
moscope, I  would  introduce  a  long  needle  (somewhat 
longer  than  the  one  shown  in  Fig.  41)  through  the  side 
of  the  eye,  under  the  guidance  of  the  ophthalmoscope,  bring- 
ing the  point  of  the  needle  in  contact  with  the  splinter,  and 
in  that  way  loosening  it  up  and  drawing  it  forward. 


FOREIGN  BODIES  FROM  INTERIOR   OF  EYE.    233 

To  draw  a  splinter  forward  from  behind  the  iris  and 
through  the  pupil  into  the  anterior  chamber  again  often 
requires  a  good  deal  of  patience  and  correct  technic.  A 
smooth  splinter  not  infrequently  at  (»nee  slips  to  the  front 
when  the  eye  is  turned  in  the  right  direction.  If  the  cur- 
rent is  opened  immediately  after  bulging  of  the  iris  takes 
place,  so  that  the  splinter  can  not  puncture  the  posterior 
surface  of  the  structure,  no  difficulty  is,  as  a  rule,  experi- 
enced in  bringing  it  into  the  anterior  chamber,  especially 
when  previous  dilation  of  the  pupil  has  been  possible. 
So  far,  I  have  never  been  compelled  to  perform  iridectomy 
in  order  to  get  the  splinter  out  from  behind  the  iris.  In 
two  cases  I  performed  a  mild  iridodialysis  by  seizing  the 
iris  with  the  forceps  and  pushing  it  slightly  toward  the 
center,  thus  tearing  it  loose  for  a  short  distance  at  the  cili- 
ary border,  and  through  this  tear  I  then  successfully 
extracted  the  spicule,  which  was  lodged  between  the  root 
of  the  iris  and  the  ciliary  body.  In  former  years  I  once 
or  twice  succeeded  in  getting  a  splinter,  which  was  lodged 
fast  behind  the  iris,  by  means  of  a  small  smooth  attach- 
ment to  the  small  Fröhlich  electromagnet,  specially  de- 
signed for  the  anterior  chamber,  which  I  introduced 
through  an  incision  in  the  cornea  and  through  the  pupil 
and  carried  behind  the  iris.  W.  Lang  recommends  a  sim- 
ilar procedure  with  a  smooth  steel  spatula  (Fig.  75),  which 
he  carries  behind  the  iris,  through  a  corneal  incision  made 
opposite  the  spot  where  the  splinter  is  lodged,  and  then 
magnetizes  by  having  the  assistant  bring  into  contact  with 
the  spatula  a  long,  flexible  piece  of  cable,  about  J  cm. 
thick  and  about  25  cm.  long,  containing  soft  iron  wire  and 
fastened  to  a  magnet.  After  the  splinter  has  been  drawn 
through  the  pupil  into  the  anterior  chamber,  in  the  man- 
ner described  above,  there  remains,  as  the  last  step  in  the 
operation,  its  final  extraction.  This  also  requires  a  cool 
head  and  a  steady  hand.  The  small  magnet  may  be  used 
for  the  purpose,  if  desired  ;  the  patient  may  be  laid  upon 
the  operating  table,  and  the  splinter  extracted  through  a 
suitable  corneal  incision  by  introducing  the  magnet  into 


234  OPERATIONS  ON  THE  EYE. 

the  anterior  chamber.  Personally,  I  prefer  to  finish  the 
operation  with  the  large  magnet.  In  the  last  68  operations 
I  did  not  use  the  small  magnet  at  all,  and  in  the  last  150 
only  three  times.  While  the  patient  is  still  seated  in  front 
of  the  magnet,  I  make  a  vertical  incision,  about  5  mm.  in 
length,  at  the  proper  point  in  the  cornea,  using  a  Gräfe 
cataract-knife,  without  causing  escape  of  aqueous  humor. 
The  eye  is  then  brought  close  to  the  sharp  pole  of  the 
magnet  until  the  splinter,  if  it  is  small,  rises  and  floats  free 
in  the  anterior  chamber,  with  one  end  touching  the  incision. 
The  patient's  head  is  then  manipulated  so  as  to  press  the 
point  of  the  magnet  lightly  in  the  corneal  wound,  where- 
upon the  magnet,  as  a  rule,  at  once  seizes  and  holds  the 
foreign  body.  If  the  splinter  is  somewhat  larger,  one  end 
of  it  is  gradually  drawn  up  to  the  corneal  wound  with  the 
point  of  the  magnet,  and  the  sharp  pole  is  then  inserted 
into  the  wound  so  as  to  distend  it  slightly.  Two  points 
should  be  insisted  upon  :  The  incision  should  not  be  too 
small,  and  in  manipulating  the  head  to  extract  the  foreign 
body  the  aqueous  humor  must  not  be  allowed  to  escape 
prematurely,  as  a  splinter  wedged  between  the  iris  and  the 
cornea  is  very  difficult  to  extract  and  may  endanger  the 
integrity  of  the  lens. 

In  the  not  very  rare  cases  in  which  the  presence  of  the 
foreign  body  has  already  led  to  infection,  and  hypopyon, 
for  example,  has  developed  in  consequence,  a  pencil  of 
iodoform  is  to  be  introduced  in  the  anterior  chamber, 
through  the  corneal  incision,  before  the  operation  is  termi- 
nated (see  Plate  1). 

When  a  large  splinter  has  made  a  correspondingly 
large  wound  at  the  corneal  or  scleral  margin,  or  has  per- 
forated the  sclera  farther  back,  an  attempt  may  be  made 
to  extract  it  by  gently  pressing  the  sharp  point  of  the 
magnet  into  the  wound  and  then  closing  the  current.  The 
old  method  of  introducing  the  small  magnet  from  the  side 
may  also  be  employed  for  the  removal  of  large  splinters, 
as  in  most  cases  of  this  kind  no  more  than  moderate  vision 
can  be  hoped  for.     When  the  destruction  has  been  exten- 


FOREIGN  BODIES  FROM  INTERIOR   OF  EYE.    235 

sive,  as  is  often  the  ease  when  a  large  splinter  has  entered 
the  interior  of  the  eye,  the  surgeon  must  be  satisfied  to 
preserve  a  sightless  orb. 

AVhen  an  iron  splinter  lodges  in  the  lens,  which  is  not 
a  very  frequent  accident,  it  can  be  extracted  with  no  diffi- 
culty whatever  by  means  of  the  large  magnet.  When 
such  a  foreign  body  has  lodged  behind  the  lens,  it  can  also, 
as  a  rule,  be  readily  drawn  forward  into  the  anterior 
chamber.  If  the  capsule  offers  any  resistance,  it  must  be 
opened  with  a  discission-needle. 

With  regard  to  the  risks  that  attend  the  procedure  I 
have  proposed,  much  has  been  said  about  them  by  the 
adherents  of  the  small  magnet,  although  most  of  them  are 
without  any  practical  experience  whatever.  The  risk  is, 
however,  much  less  than  when  the  old  method  with  the 
small  magnet  is  used  ;  in  fact,  the  large  magnet  is  only 
dangerous  when  it  is  not  properly  handled.  For  example, 
when  there  is  a  splinter  behind  the  iris,  the  operator  should 
not  attempt  to  extract  it  from  the  eye  by  making  a  corneal 
incision  and  then  drawing  the  splinter  through  that  in- 
cision and  through  the  iris.  It  is  so  difficult  for  a  splinter, 
even  when  it  is  sharp  and  pointed,  to  pass  through  the 
iris,  that  it  is  much  more  likely,  if  the  above  attempt  is 
made,  to  bring  the  iris  along  with  it  and  tear  it  out  of  the 
eye.  Hence  the  point  of  the  splinter  at  least  must  be  free 
in  the  anterior  chamber  before  any  attempt  is  made  to 
extract  it  directly  through  the  cornea  with  the  large  mag- 
net. It  is  a  purely  theoretic  objection  that,  when  a 
splinter  is  drawn  forward  by  the  magnet,  it  endangers  the 
ciliary  body  or  the  lens.  Even  occasional  dragging  and 
distortion  of  the  iris  by  the  foreign  body  as  it  is  drawn 
forward  is  of  no  significance.  Purely  mechanic  injuries, 
as  is  well  known,  do  but  little  harm  to  the  ciliary  body  or 
to  the  iris  ;  and  as  regards  the  lens,  among  my  series  of 
about  200  operations  I  had  only  3  cases  in  which  the  lens 
was  injured  by  the  splinter  as  it  was  drawn  forward.  Be- 
sides, I  consider  a  traumatic  cataract  less  grave  than  the 
introduction  of  the  small  magnet  into  the  vitreous. 


230  OPERATIONS  ON  THE  EYE. 

For  the  rest,  the  results  of  the  operation  with  the  large  magnet 
speak  for  themselves.  In  my  first  190  cases  the  splinter  was  extracted 
166  times,  or  in  87  per  cent.;  among  the  first  134  difficult  cases,  in 
which  the  splinter  was  drawn  forward  from  behind  the  iris  and  the 
lens,  it  was  extracted  111  times,  or  in  83  per  cent.  In  34  of  these  134 
cases  the  splinter  was  proved  to  have  been  lodged  in  or  close  to  the 
retina,  but  in  spite  of  that  it  was  driven  back  from  its  lodging  place 
and  extracted  from  the  eye  in  28  cases.  Of  my  first  165  cases,  55,  or 
33.3  per  cent,,  recovered  with  good  vision,  as  was  actually  demonstrated, 
and  in  21  other  cases  the  prospect  for  subsequent  improvement  of  the 
vision  by  operation  was  good  (cataract  operation).  If  we  include  the 
latter  among  the  former  list,  it  would  give  us  for  the  entire  number 
(including  the  negative  ones)  40  per  cent,  for  the  141  cases  in  which 
the  splinter  was  extracted,  56  per  cent,  with  a  useful  eye.  The  results 
obtained  in  other  clinics  with  the  large  magnet  are  equally  favorable. 

When  should  the  small  magnet  be  used  ?  The  answer 
to  this  question  is  :  as  little  as  possible  in  the  region  of 
the  vitreous,  and  whenever  the  operator  desires  in  the 
region  of  the  anterior  chamber.  That  it  can  be  dispensed 
with  altogether  is  shown  by  my  series  of  operations.  The 
indications  for  the  use  of  the  somewhat  larger  hand  mag- 
nets, which,  after  the  introduction  of  the  larger  magnet, 
were  partly  developed  from  small  ones  like  that  of  Hirsch- 
berg, and  partly  designed  anew  by  Johnson,  Sweet,  and 
Volkmann,  possess  a  somewhat  wider  field.  They  have  an 
essentially  greater  power  than  the  ordinary  small  magnets, 
and,  therefore,  also  somewhat  more  effect  at  a  distance 
than  the  latter  possess.  [Fully  admitting  and  admir- 
ing the  value  of  Haab's  giant  magnet  and  the  great  ser- 
vice it  has  rendered  to  ophthalmic  practice,  it  is  proper 
to  reiterate  here  the  statement  that  equally  good  results 
may  be  obtained  by  accurately  localizing  the  foreign  body 
by  means  of  the  .T-rays,  and  removing  it  through  an  inci- 
sion placed  according  to  the  localization.  This  incision  is 
small,  heals  readily,  and  apparently  leaves  no  evil  result. 
The  magnet — it  may  be  a  giant  magnet,  or  a  smaller  one, 
for  example,  Sweet's  magnet — is  placed  at  the  lips  of  the 
wound  and  does  not  enter  the  vitreous  chamber.  The 
body  is  immediately  extracted  and  does  not  make  a  long 
journey  through  the  eye.  Sweet's  method  of  localizing, 
by  means  of   which  the  smallest   particles   of  steel   are 


FOREIGN  BODIES  FROM   INTERIOR   OF  EYE.    237 

detected,  has  again  and  again  been  shown  to  be  perfectly 
accurate.  If  the  z-rays  can  not  be  utilized  in  this  respect, 
and  often  the  means  for  employing  them  are  not  at  hand, 
the  method  described  by  Prof.  Haab  yields  the  best 
results  and  should  be  resorted  to  with  as  little  delay  as 
possible. — Ed.] 

(b)  Removal  from  the   Interior  of  the  Eye  of  Foreign 
Bodies   Not  Consisting  of  Iron. 

This  variety  of  foreign  bodies  is  most  apt  to  be  found 
in  the  anterior  chamber.  When  the  particle  of  copper, 
stone,  wood  or  other  material  has  lodged  on  the  iris,  it  can 
usually  be  removed  with  a  pair  of  iris  forceps  through  a 
suitable  corneal  incision,  after  the  pupil  has  been  well 
contracted  by  means  of  physostigmin,  and  without  per- 
forming an  iridectomy.  If  the  iris  prolapse  into  the 
wound,  it  should  be  replaced.  But  if  the  splinter  be 
solidly  embedded  in  the  tissue  of  the  iris,  a  small  piece 
of  the  cnrtain  will  have  to  be  seized  with  it.  For  the 
removal  of  cilia  and  oblong  or  linear  foreign  bodies,  a 
blunt  hook  may  also  do  good  service  (Figs.  67  and  68). 
In  many  cases  a  forceps  with  thin  transverse  serrations  <>r 
with  spoon-shaped  extremities  is  preferable  to  a  conjunc- 
tival forceps.  Knapp's  hollow  hook  is  sometimes  quite 
serviceable. 

"When  the  splinter  is  wedged  fast  in  the  groove  between 
the  iris  and  cornea,  usually  the  lower  portion,  I  have 
found  by  experience  that  it  is  best  to  make  a  large  cor- 
neal flap-incision  at  the  corneal  border,  and,  after  raising 
the  latter  with  a  double  hook  (Fig.  72),  have  an  assistant 
hold  the  iris  in  position  with  a  spatula — as  otherwise  the 
curtain  falls  over  the  foreign  body  and  covers  it  up — and 
carefully  pick  out  the  splinter  with  a  suitable  instrument. 
Forceps  should  be  avoided  altogether  in  such  cases, 
because  the  foreign  body,  which  may  be  partially  embedded 
in  the  iris,  is  apt  to  be  pushed  all  the  way  through  the 
curtain  and  pass  entirely  out  of   reach.     For  the   same 


238  OPERATIONS  ON  THE  EYE. 

reason  care  must  be  exercised  in  making  the  flap  not  to 
exert  any  pressure  on  the  splinter.  Turning  back  the 
cornea,  a  procedure  which  has  also  been  recommended  by 
Knapp  and  Gayet,  offers  the  readiest  access  to  the  ante- 
rior chamber  without  injuring  the  membrane. 

Foreign  bodies  in  the  lens,  consisting  of  some  material 
other  than  iron,  are  to  be  treated  as  described  on  p.  110. 

The  presence  of  a  splinter  of  this  kind  in  the  vitreous 
constitutes  a  much  more  serious  injury  than  does  the  pres- 
ence of  an  iron  spicule ;  for  its  removal  presents  great 
difficulties  and,  as  a  rule,  necessitates  going  in  from  the 
side  through  the  sclera — that  is  to  say,  in  most  cases,  an 
incision,  through  which  an  attempt  must  be  made  to 
extract  the  foreign  body.  It  is  not  usually  possible  to 
seize  the  body  with  forceps,  unless  it  is  embedded  in  exu- 
date which  offers  a  hold  for  the  jaws  of  the  forceps.  I 
once  extracted  a  cartridge  splinter  through  a  scleral  inci- 
sion, four  and  one-half  days  after  it  had  entered  the  eye, 
by  obtaining  a  hold  on  the  thin  exudate  by  which  it  was 
surrounded.  Recovery  ensued  with  normal  vision,  but 
four  years  later  a  retinal  detachment  developed.  I 
adopted  a  somewhat  different  plan  in  another  case  of  a 
percussion-cap  explosion,  in  which  a  smooth  piece  of 
copper  had  entered  the  vitreous,  and  the  other  eye  had 
also  been  injured  by  the  same  explosion.  A  small  inci- 
sion was  made  in  the  sclera  with  a  Gräfe  knife,  and,  with 
the  aid  of  a  head  mirror,  with  which  the  splinter  can  be 
readily  seen,  the  pupil  was  dilated,  a  Desmarres'  capsule 
forceps  (Fig.  54)  introduced  and,  after  the  delicate  forceps 
had  been  opened  and  closed  a  number  of  times  by  means 
of  the  lever  attached  to  the  handle,  I  finally  succeeded  in 
seizing  the  elusive  splinter  and  extracted  it  without  any 
of  the  vitreous  escaping  through  the  small  incision, 
which  was  completely  stopped  by  the  instrument  during 
my  attempts  at  seizing  the  foreign  body,  and  without  the 
instrument  causing  any  considerable  destruction  in  the 
vitreous.  This  operation  convinced  me  how  difficult  it  is 
to  get  hold  of  a  foreign  body  in  the  vitreous,  even  when 


OPERATIONS  ON  THE  OCULAR   MUSCLES.       239 

both  it  and  the  instrument  can  be  kept  constantly  in  plain 
view.  I  may  recommend  Desmarres'  forceps  for  suitable 
cases  as  one  of  the  least  destructive  instruments. 

Knapp's  hollow  hook  can  also  be  used  for  extracting 
splinters  of  this  kind. 


B.  OPERATIONS  OUTSIDE  OF  THE  EYEBALL. 
I.  OPERATIONS  ON  THE  OCULAR  MUSCLES. 

Strabismus. 

The  correction  of  strabismus,  whether  it  be  paralytic 
or  of  the  more  frequent  concomitant  variety,  often,  but 
not  always,  requires  operative  intervention.  Operative 
procedures  should  always  be  based  on  accurate  examina- 
tion. The  question  which  of  the  two  varieties  of  strabis- 
mus is  present  must  be  accurately  determined  (see  my 
Atlas  and  Epitome  of  External  Diseases  of  the  Eye,  second 
edition,  p.  73),  and  in  the  case  of  concomitant  squint  it 
must  also  be  determined  whether  it  is  convergent  or 
divergent,  with  or  without  simultaneous  upward  devia- 
tion, whether  the  squint  occurs  only  periodically  or  is 
constant,  whether  it  is  unilateral  or  alternating  (now  on 
the  right  and  now  on  the  left  side),  the  magnitude  of  the 
squint  angle,  the  condition  of  visual  acuity  and  the  refrac- 
tion of  both  eyes  (either  in  the  erect  image  or  with  the 
shadow  test),  and  the  movability  of  the  globes  (as  regards 
abduction,  convergence,  etc.). 

It  is  an  important  principle  in  the  treatment  of  strabis- 
mus never  to  operate  until  every  other  mode  of  treatment 
has  failed — i.  e.,  in  case  of  paralytic  squint,  causal  treat- 
ment ;  and  in  case  of  convergent  squint,  suitable  exercises 
and  the  necessary  correcting  glasses.  In  concomitant, 
divergent  squint,  operation,  it  is  true,  is  the  only  effective 
treatment ;  something,  however,  can  be  done  for  this 
variety  of  squint,  which  in  many  cases  is  combined  with 
myopia,  by  ordering  the  necessary  concave  lenses.     Con- 


240  OP  ERAT  10  SS  ON  THE  EYE. 

vergent  strabismus,  on  the  other  hand,  which  occurs  more 
commonly  in  hypermetropia,  and  in  many  cases  is  prob- 
ably enhanced  by  increased  accommodation  and  the  asso- 
ciated increased  convergence,  is  often  favorably  influenced 
by  convex  lenses  which  neutralize  the  refractive  error. 
In  both  varieties  of  strabismus,  astigmatism  must  be  cor- 
rected at  the  same  time,  so  as  to  give  both  eyes  the  best 
possible  far  and  near  vision  and  thereby  render  binocular 
vision  as  perfect  as  possible. 

If  this  treatment  fails  and  operation  has  to  be  resorted 
to,  the  operator  must  never  overlook  this  important  rule : 
The  operation  must  be  such  as  not  to  diminish  the  mo- 
bility of  the  globe  in  the  domain  of  the  corrected  muscles. 

The  fundamental  principle  of  a  strabismus  operation 
consists  in  advancing  the  muscle,  if  its  action  is  to  be  in- 
creased, and  moving  it  back  if  its  action,  on  the  other 
hand,  is  to  be  limited.  The  procedure  is  confined  abso- 
lutely to  the  tendinous  insertions  and  their  immediate 
neighborhood.  Division  of  the  muscle,  which  was  recom- 
mended by  Strohmeyer,  and  first  performed  by  DieiFenbach 
in  1839,  was  incorrect  because  it  put  the  muscles  out  of 
action.  It  was  this  method  that  brought  discredit  upon 
strabismus  operations  until  Bonnet,  Böhm,  Guerin,  and 
especially  A.  von  Gräfe,  later  also  Critchett,  A.  Weber 
and  others  established  the  operations  of  tenotomy  and 
advancement  on  a  correct  basis  in  harmony  with  the  ana- 
tomic conditions.  Even  now,  however,  the  operation  for 
the  correction  of  strabismus,  taken  in  connection  with  the 
entire  treatment  of  squint,  is  the  subject  which  is  most 
hotly  discussed,  and,  if  only  the  permanent  results  are 
taken  into  consideration,  it  is  the  least  satisfactory  of  all 
operative  procedures  on  the  eye.  The  treatment  is  far 
from  being  simple,  either  in  principle  or  in  execution,  as 
was  formerly  supposed  when  tenotomy,  the  simplicity  of 
which  can  not  be  denied,  was  almost  exclusively  practised, 
and  there  is  no  doubt  whatever  that  advancement,  although 
more  difficult  and  more  unpleasant  to  the  patient,  deserves 
more  consideration  than  it  has  so  far  received.     In  the 


OPERATIONS  ON  THE   OCULAR  MUSCLES.       241 

same  way  greater  attention  should  be  given  to  the  sug- 
gestions of  Javal,  Priestley  Smith  and  Worth,  that  stra- 
bismus be  treated  in  early  childhood  with  suitable  correcting 
lenses  and  exercises,  in  order  to  maintain  or  restore  cen- 
tral, so-called  binocular,  vision,  and  as  a  preparation  for 
the  permanent  restoration  to  the  normal,  with  or  without 
operation. 

With  regard  to  the  anatomic  relations  of  the  tendinous  insertions  of 
the  muscles  in  the  globe,  the  following  is  worth  remembering:  The 
internal  and  external  rectus  end  in  a  slightly  curved  line  (with  a  con- 
vexity toward  the  cornea)  ;  the  inferior  and  superior  rectus  end  some- 
what obliquely  in  an  irregular  line,  so  that  the  distance  between  the 
insertion  line  from  the  cornea  varies  according  to  the  point  where  it  is 
measured.  For  example,  in  the  case  of  the  superior  rectus  the  nasal 
end  of  the  tendinousjnsertion  is  6.5mm.,  and  the  temporal  end  11  mm., 
from  the  cornea,  according  to  Motais  'inferior,  nasal  5.5;  temporal  8). 
For  practical  purposes  the  following  numbers,  which  ;tre  easy  to  re- 
member, will  sumce :  right  internal  rectus  5  mm.,  inferior  rectus  ö  mm., 
external  rectus  7  mm.,  superior  rectus  8  mm.,  measured  at  about  the 
center  of  the  tendon. 

It  is  also  important  that  the  tendons  of  the  four  straight  muscles  of 
the  eye  should  not  only  be  adherent  to  the  sclera  along  the  above-men- 
tioned insertion  line  from  9  to  11  mm.  in  length ;  they  must  also  be 
laterally  in  relation  with  Tenon's  capsule,  so  that,  when  a  tendon  is 
only  separated  in  front  at  its  scleral  insertion.it  retracts  only  a  short 
distance,  say  4  to  5  mm.,  because  of  the  above-mentioned  attachment  to 
Tenon's  capsule,  and  the  reduction  in  the  power  of  the  muscle  is  there- 
fore correspondingly  moderate,  and  the  gain  to  the  antagonist  corre- 
spondingly small,  if  the  latter  possesses  the  strength  to  rotate  the  bulb 
a  corresponding  distance  over  to  its  own  side.  The  effect  of  separating 
the  tendons  on  the  position  of  the  eye,  therefore,  depends  very  largely 
on  the  contractile  power  of  the  antagonistic  muscle.  The  retracting 
tendon  then  forms  a  fresh  adhesion  with  the  sclera. 

The  preparations  for  a  strabismus  operation  consist  in 
cleansing,  local  anesthesia  by  the  injection  of  2  drops  of 
a  2  per  cent,  cocain  solution  with  a  drop  of  adrenalin 
under  the  conjunctiva  (if  necessary  general  anesthesia, 
see  p.  26),  and  a  delay  of  five  to  ten  minutes,  during 
which  the  eyeball  is  subjected  to  gentle  massage. 

There  is  no  ground  for  the  objection  that  has  been 
made  against  injecting  cocain  in  this  ^vay — that  it  greatly 
disturbs  the  topography  of  the  operative  field  ;  while,  on 
the  other  hand,  it  is  most  agreeable  for  the  patient,  espe- 

16 


242  OPERATIONS  ON  THE  EYE. 

Figs.  87-93. — Instruments  for  tenotomy : 
Fig.  87. — Clark's  eye-speculum  (Weiss,  London). 
Fig.  88. — Straight  conjunctival  forceps. 
Fig.  89. — Strabismus-hook,  large. 
Fig.  90. — Strabismus-hook,  small  (Stevens). 
Fig.  91. — Strabismus-scissors,  bent,  with  the  blunt  ends. 
Fig.  92. — Strabismus-scissors,  straight  (Stevens). 
Fig.  93.— Needle-holder  (Sands). 


cially  in  the  case  of  children,  and,  as  it  prevents  all  the 
struggles  that  are  otherwise  apt  to  take  place,  it  is  an  im- 
portant aid  in  guarding  against  any  interruption  of  the 
operation.  In  the  case  of  excitable  children,^ who  some- 
times become  unmanageable,  even  when  they  do  not  suffer 
pain,  it  is  well  to  have  the  bent  forceps  (Fig.  22)  ready,  so 
that,  if  necessary,  the  assistant  may  rotate  the  globe 
toward  the  proper  side  and,  especially  in  tenotomy  of  the 
internus,  provide  easy  access  to  the  insertion  of  the 
tendon.  For  the  rest,  the  instruments  shown  in  Figs.  87 
to  93  are  necessary  or,  at  least,  desirable  for  the  operation. 
It  is  most  important  never  to  use  sharp  scissors  for 
tenotomy,  on  account  of  the  danger  of  injuring  the  sclera. 
It  must  also  be  borne  in  mind  that  the  sclera  underneath 
the  muscular  tendons  may  not  be  more  than  0.2  mm.  in 
thickness. 

The  operator  takes  up  his  position  in  such  a  way  that 
the  insertion  of  the  tendon  which  is  to  be  cut  is  opposite 
his  right  hand — that  is,  when  the  left  internal  rectus  is  to 
be  cut,  he  stands  to  the  left  of  the  patient. 

(1)  Tenotomy  after  von  Gräfe. — A  vertical  incision 
5  to  6  mm.  in  length  is  made  in  the  conjunctiva  between 
the  cornea  and  the  insertion  of  the  tendon,  the  cornea  is 
picked  up  with  a  sharp  forceps  (Fig.  88),  and  a  vertical 
incision  is  made  between  the  cornea  and  the  tendon.  The 
membrane  is  then  thoroughly  undermined  with  the  scissors 
in  the  direction  of  the  muscles.  This  is  particularly  neces- 
sary in  case  of  tenotomy  of  the  internal  rectus,  to  guard 
against  the  cornea  being  subsequently  drawn  back  by  the 
retracting  muscle  and  causing  a  disfiguring  deepening  of 


244  OPERATIONS  ON  THE  EYE. 

the  inner  canthus.  The  conjunctiva  should  be  well  un- 
dermined with  the  scissors  as  far  as  the  caruncle.  It 
must  also  be  undermined  in  the  direction  in  which  the 
strabisin us-hook  is  to  be  introduced  under  the  muscle — 
that  is,  in  the  case  of  the  left  internal  rectus,  above  the 
tendon,  so  as  to  make  room  for  the  hook — the  peripheral 
edge  of  the  conjunctival  wound  being  constantly  elevated 
with  the  forceps,  which  is  also  kept  up  while  the  strabis- 
mus-hook (Fig.  89)  is  introduced.  To  make  sure  that  the 
hook  gets  under  the  tendon,  it  is  first  pushed  under  the 
conjunctiva  with  the  point  away  from  the  tendon — for 
example,  in  tenotomy  of  the  left  internal  rectus  it  is 
directed  toward  the  forehead.  It  is  then  rotated  so  that 
the  point  is  pressed  somewhat  vigorously  against  the 
globe  and  thus  glides  under  the  tendon,  at  the  same  time 
transfixing  Tenon's  capsule  to  one  side  of  the  tendon. 
This  is  the  most  important  step  in  the  operation.  It  is 
more  likely  to  succeed  if  the  bulb  is  rotated  toward  the 
side  of  the  antagonistic  muscle,  either  in  response  to  com- 
mand or  passively  by  the  curved  forceps  in  the  assistant's 
hand.  If  the  hook  has  seized  the  tendon  properly,  some 
resistance  is  felt  as  the  instrument  is  drawn  forward.  The 
handle  is  then  changed  from  the  right  to  the  left  hand, 
after  the  forceps  has  been  laid  down ;  and  with  the 
strabismus-scissors  the  tendon  is  then  divided  in  a  manner 
similar  to  that  shown  in  Plate  8,  except  that  in  that  illus- 
tration the  instrument  is  a  double  hook  and  the  wound  is 
larger  than  in  the  case  of  tenotomy.  With  the  same  hook 
or  with  a  smaller  one  (as  for  example,  Stevens',  Fig.  90) 
the  operator  makes  sure  that  he  has  not  left  either  above 
or  below,  at  the  insertion  in  the  tendon,  a  small  portion 
of  tendon  fibers  ;  if  any  are  found,  they  are,  of  course,  to 
be  divided.  He  also  makes  sure  that  the  tendon  does  not 
possess  a  second,  less  perfectly  developed,  attachment  to 
the  sclera  farther  back,  formed  by  a  few  fibers  of  con- 
nective tissue  passing  through  the  lower  surface  of  the 
tendon  to  the  sclera.  These,  if  they  are  present,  must 
also  be  divided,  otherwise  the  operation  is  unsuccessful. 


OPERATIONS  ON  THE  OCULAR  MUSCLES.       245 

It  may  also  appear,  when  the  effect  is  tested — which 
must  be  clone  immediately  after  the  operation — that  the 
separation  has  been  incomplete.  The  mobility  of  the  eye 
is  examined.  If  it  is  found  that  the  excursion  toward 
the  side  of  the  tenotomized  muscle  is  as  great  as  it  was 
before,  the  wound  should  be  examined  to  determine 
whether  some  portions  of  the  tendon  have  escaped  divi- 
sion. If  the  operation  has  been  properly  performed,  a 
moderate  diminution  in  the  mobility,  proportionate  to 
the  tenotomy,  is  observed.  This  reduction  must  not  be 
too  great,  however.  After  tenotomy  of  the  internal  rectus 
the  patient  should  have  sufficient  convergence  to  enable 
him  to  see  the  operator's  finger,  held  in  front  of  him  at  a 
distance  of  about  12  cm.,  with  both  eyes.  If  too  much 
of  the  tendon  has  been  separated  from  its  lateral  connec- 
tions with  Tenon's  capsule,  as  may  happen  if  the  hook  is 
handled  too  roughly  or  the  lateral  connections  of  the 
tendon  are  separated  with  the  scissors — resulting  in  a 
faulty  reduction  of  mobility — the  effect  of  the  tenotomy 
should  at  once  be  counteracted  by  inserting  a  restraining 
suture  through  the  side  of  the  tendon  and  including 
Tenon's  capsule,  drawing  the  latter,  as  well  as  the  tendon, 
forward.  The  gaping  wound  in  the  conjunctiva  is  now 
closed  merely  with  a  superficial  suture,  as  at  the  end  of  a 
regular  operation.  The  suture  may  be  rendered  still 
more  effective  by  introducing  two  needles,  one  above  and 
the  other  below  the  tendon,  through  conjunctiva  and 
Tenon's  capsule  and  then  through  the  zone  of  conjunc- 
tiva, between  the  cornea  and  the  wound ;  the  needles  are 
then  removed  and  the  suture  tied. 

A  single  bandage  and  a  few  hours'  rest  are  indicated, 
although,  if  necessary,  the  operation  may  be  performed  on 
walking  patients.  [The  editor  believes  that  both  eyes 
should  be  bandaged ;  or  better,  if  possible,  the  correcting 
glasses  should  be  worn  without  a  bandage  immediately 
after  the  operation. — Ed.] 

(2)  Tenotomy  after  Arlt  is  performed  as  follows : 
The  eyeball  having  been  rotated  toward  the  side  of  the 


246  OPERATIONS  ON  THE  EYE. 

Fig.  94. — de  Wecker's  hooks  for  muscle  advancement. 
Fig.  95. — Prince's  forceps  for  muscle  advancement. 
Fig.  96. — Angular  (raven-beak)  scissors  for  dividing  the  tendon  (Lan- 
dolt). 

Fig.  97.— Needle-holder  (Weiss,  London). 

antagonist,  the  conjunctiva  is  seized  with  a  sharp  conjunc- 
tival forceps,  a  little  to  the  corneal  side  of  the  insertion  of 
the  corresponding  tendon,  and  drawn  slightly  away  from  the 
globe.  The  fold  thus  produced  is  then  nicked  with  stra- 
bismus-scissors, and  the  opening  enlarged  upward  and 
downward,  so  as  to  make  a  vertical  wound  from  8  to  10 
mm.  in  length  ;  from  this  wound  the  conjunctiva  is  then 
undermined  in  the  direction  of  the  tendon.  The  tendon 
is  then  seized  with  the  same  sharp  forceps,  which  is  held 
perpendicularly  to  the  globe.  The  tendon  is  also  lifted 
slightly  away  from  the  globe  and  divided  with  the  scis- 
sors close  to  its  insertion.  The  strabismus-hook  is  then 
introduced  to  make  sure  that  none  of  the  fibers  of  the 
tendon  has  escaped.  The  effect  of  the  operation  is  then 
tested  and,  if  necessary,  corrected  as  in  the  foregoing 
operation ;  or  the  operation  is  terminated  at  once.  A 
suture  is  inserted  in  the  conjunctiva,  and  the  after-treat- 
ment is  the  same  as  in  the  foregoing  operation. 

(3)  Tenotomy  after  Snellen  is  similar  to  the  fore- 
going. Snellen  makes  a  horizontal  incision  in  the  cornea, 
over  the  center  of  the  tendon  (as  von  Gräfe  occasionally  did 
and  advised) ;  undermines  the  mucous  membrane  laterally 
on  both  sides  and  in  the  direction  of  the  tendon  (in  the 
case  of  the  internus  as  far  as  the  caruncle),  seizes  the 
tendon  with  the  conjunctival  forceps ;  and  first  makes  a 
small  opening  at  the  center  of  its  insertion.  Introducing 
the  scissors  through  this  opening,  he  then  gently  pushes 
the  instrument  well  under  the  insertion  of  the  tendon, 
both  above  and  below,  so  as  to  divide  the  tendon  with  the 
least  amount  of  damage  and  without  distorting  or  dis- 
placing it.  The  after-treatment  is  the  same  as  in  the  fore- 
going operation. 

Tenotomy,  which  restricts  the  sphere  of  action  of  the 


247 


248  OPERATIONS  ON  THE  EYE. 

muscle,  often  needs  to  be  combined  with  an  operation  to 
increase  the  action  of  the  corresponding  antagonist.  Thus, 
in  severe  cases  of  divergent  squint,  unilateral  or  bilateral 
tenotomy  of  the  externus  would  not  accomplish  the  desired 
result  if  one  or  both  inward  rotators  were  not  also  util- 
ized to  correct  the  condition,  and  the  same  is  true  of  the 
outward  rotators  in  the  case  of  severe  convergent  squint. 
Such  an  operation  to  increase  the  action  of  a  muscle  is 
indicated  specially  in  paralytic  squint  and  when,  as  a 
result  of  strabismus  of  long  standing,  the  action  of  the 
antagonist  of  the  squinting  muscle,  abduction  in  conver- 
gent squint,  has  become  very  deficient.  The  corrective 
operation  may  also  become  necessary  to  advance  a  muscle 
that  has  receded  too  far  after  tenotomy  or  myotomy,  and 
to  strengthen  its  action. 

This  latter  indication  led  to  the  development  of  advancement  of 
tendons,  which  was  performed  in  the  early  days  of  strabismus  opera- 
tions to  correct  the  movements  of  an  eye  that  had  been  damaged  by 
myotomy  (instead  of  tenotomy)  and  had  developed  strabismus  of  the 
opposite  type.  Dieffenbach  treated  this  secondary  form  of  strabismus 
by  searching  for  the  retracted  muscle  and  fastening  it,  by  means  of  a 
suture,  to  the  anterior  portion  of  the  globe  after  it  had  been  rotated 
inward;  or,  by  freshening  the  edges,  united  the  muscle  with  a  fine 
suture — that  is  to  say,  he  attached  the  abnormally  retracted  muscle  to 
its  tendon. 

Guerin  in  1849  and,  later,  von  Gräfe,  brought  the  retracted  muscle 
forward  by  searching  for  it  and  separating  it  from  the  globe.  The  eye 
was  then  rotated  toward  the  muscle  which  was  to  be  advanced  until  the 
insertion  corresponded  with  the  cornea — that  is  to  say,  it  was  advanced 
beyond  the  true  insertion.  Rotation  was  effected  by  means  of  a 
suture  in  the  manner  already  practised  by  Dieffenbach,  GueYin  passing 
the  suture  through  the  conjunctiva  to  the  temporal  side  of  the  cornea, 
while  von  Gräfe  did  a  tenotomy  on  the  abducens  and  attached  the  suture 
to  the  tendon  stump.  By  means  of  this  suture,  which  was  fastened  to 
the  root  of  the  nose  writh  adhesive  plaster,  or,  in  the  case  of  abduction, 
to  the  cheek,  the  eye  was  maintained  in  the  forced  position  for  several 
days,  during  which  a  bandage  was  applied  in  order  to  compel  the 
retracting  muscle  to  form  a  new  insertion  in  front.  But  as,  like  every 
other  muscle,  it  was  apt  to  contract,  it  sometimes  grew  fast  too  far  back 
on  the  globe,  in  spite  of  this  precaution.  This  operation,  which  causes 
the  patient  pain  and  compels  him  to  keep  quiet  for  several  days,  was 
known  as  the  suture  operation.  It  was  compelled  to  yield  the  floor  to 
actual  advancement  and  suturing  of  the  tendon,  which  was  first  per- 
formed by  Dieffenbach  and  then  elaborated   by  Critchett,  von  Gräfe, 


OPERATIONS  ON  THE  OCULAR  MUSCLES.       249 

Knapp,  AVeber,  de  Wecker,  and  many  others.  Critchett  suggested  as 
an  improvement  the  introduction  of  3  sutures.  He  made  a  vertical 
incision  in  the  conjunctiva,  between  the  cornea  and  the  tendinous  inser- 
tion, and  through  it  introduced  a  strabismus-hook  behind  the  tendon, 
thus  separating  it  from  the  sclera.  He  then  cut  away  a  strip  from  the 
peripheral  edge  of  the  wound  and  united  it  by  means  of  3  sutures 
introduced  in  a  horizontal  direction  above,  at  the  center  and  below, 
including  the  piece  of  conjunctiva  remaining  at  the  corneal  margin 
and  taking  a  deep  hold  on  the  peripheral  ^d^e  of  the  wound.  When 
the  three  sutures  were  tied  the  tendon  was  drawn  forward  almost  as  far 
as  the  corneal  margin. 

Operations  on  the  Antagonist  of  the  Squinting  Muscle. 

1.  Knapp's  Method. — In  order  to  make  sure  of  the 
effect  of  the  advancement,  Knapp  does  a  thorough  tenot- 
omy on  the  squinting  muscle,  and  then  introduces  the 
sutures  toward  the  equator,  through  the  tendon  and  con- 
junctiva. He  inserts  4  to  6  sutures  through  the  conjunc- 
tiva, the  subconjunctival,  and  part  of  the  scleral  tissue, 
the  intermediate  ones  near  the  horizontal  meridian,  and 
the  upper  and  lower  ones  to  one  side  and  above  and  below, 
respectively,  near  the  vertical  meridian  of  the  eye. 

2.  Weber's  Method. — Ad.  Weber,  in  his  advance- 
ment method  (1873),  followed  the  principle  of  drawing 
the  tendon  forward  toward  the  cornea  in  a  perfectly  uni- 
form manner,  avoiding  any  irregular  traction  of  the 
sutures  and,  therefore,  any  upward  and  downward  dis- 
placement of  the  tendon.  After  making  a  vertical  incision 
in  the  conjunctiva  in  front  of  the  line  of  insertion  of  the 
muscle  to  be  advanced  (between  the  line  of  insertion  and 
the  cornea),  and  undermining  the  conjunctiva  to  a  point 
beyond  the  tendon,  he  separated  the  latter  from  the  sclera 
by  seizing  it  with  forceps  and  holding  it  while  the  suture 
was  passed  through  the  center  of  the  tendon,  going  in  from 
the  scleral  side.  A  long  suture  provided  with  a  curved 
needle  at  each  end  is  folded  in  the  middle  and  passed 
double  through  a  third  needle.  By  means  of  the  third 
needle  the  thread  is  introduced  into  the  tendon  and,  a 
little  farther  back,  through  the  conjunctiva  as  well  (Fig. 
98,  a).     While  the  loop,  which  thus  comes  to  the  surface, 


250  OPERATIONS  ON  THE  EYE. 

Fig.  98. — Methods  of  advancement : 
(a)  After  Ad.  Weber. 
(6)  After  de  Wecker. 

(c)  After  Prince  (see  Plate  8). 

(d)  After  Verhoeff. 

(e)  After  Verhoeff. 
(/)  After  Worth. 

Whenever  the  suture  is  covered  by  tissue  it  is  indicated  in  the  schem- 
atic drawings  by  dotted  lines. 

is  secured  by  the  assistant,  and,  after  the  needle  has  been 
removed,  the  operator  carries  the  lower  end  of  the  suture 
between  the  conjunctiva  and  the  sclera  as  far  as  the  verti- 
cal diameter  of  the  cornea  and  far  enough  (2  to  3  mm.) 
from  the  corneal  margin  so  that  the  thread,  when  it  is 
stretched,  will  not  touch  the  cornea.  The  same  thing  is 
then  done  with  the  upper  half  of  the  suture.  The  two 
ends  of  the  suture  are  then  passed  through  the  loop  in  the 
tendon,  drawn  tight,  and  ligated  after  the  tendon  has  been 
drawn  forward  as  far  as  necessary.  But  the  knot  must 
not  slip  through  the  loop,  else  the  entire  suture  comes  out. 
It  is,  therefore,  better  to  modify  Weber's  method  by  pass- 
ing the  two  ends  of  the  suture  in  opposite  directions 
through  the  loop,  so  as  to  tie  the  loop  in  with  the  knot. 
I  saw  Horner  perform  this  modification  in  1877,  and 
Fröhlich,  who  very  frequently  used  this  method  of  ad- 
vancement— with  a  few  additional  modifications  (horizontal 
incision  in  the  cornea,  stretching  of  the  muscles — also 
ligated  the  sutures  in  this  way.  He  thinks  very  highly 
of  this  operation  on  account  of  its  simplicity,  its  practi- 
cally uniform  success,  and  its  wide  range  of  applicability. 
3.  de  Weckens  method  of  advancement  is  similar 
to  that  of  Weber.  The  double  hook  which  he  designed 
(Fig.  94)  is  very  useful,  both  for  his  own  and  for  other 
methods  of  advancement.  By  means  of  it  the  tendon  can 
be  securely  held,  and  it  is  possible,  by  holding  the  tendon 
away  from  the  globe  after  it  has  been  separated,  to  insert 
a  needle  through  the  lower  side  at  any  desired  distance 
from  the  anterior  extremity  of  the  tendon,  de  Wecker 
introduces  the  needle  in  this  direction  after  threading  it 


® 


M°) 


252  OPERATIONS  ON  THE  EYE. 

with  a  single  suture  (Fig.  98,  6)  and  drawing  it  halfway 
through,  so  that  the  needle  is  at  the  center  of  the  suture. 
The  ends  of  the  suture  are  then  again  provided  with 
needles.  After  the  middle  suture  has  been  introduced 
through  the  tendon  and  the  conjunctiva  from  the  scleral 
side,  the  needle  is  cut  away  so  that,  instead  of  Weber's 
loop,  there  are  left  two  free  ends  emerging  from  the  ten- 
don and  conjunctiva.  These  two  ends  are  then  tied  with 
the  other  ends  of  the  suture,  which  have  been  passed 
through  the  conjunctiva,  above  and  below  the  cornea,  in 
the  same  way  as  in  Weber's  operation.  The  operator 
must  be  careful  to  make  equal  traction  on  the  two  sutures, 
otherwise  the  muscle  will  be  displaced  upward  or  down- 
ward. 

4.  I^andolt's  advancement  resembles  de  Wecker's 
in  so  far  as  a  suture  is  passed  through  the  tendon  from  in 
front,  above  and  below  the  cornea ;  but  each  suture  is 
introduced  separately  (Fig.  99).  After  making  a  large 
conjunctival  flap,  so  that  the  wound  extends  almost  to  the 
cornea,  the  apex  of  the  flap  is  trimmed  off  and  an  incision 
is  made  in  Tenon's  capsule,  close  to  the  tendon,  through 
which  the  hook  is  introduced  and  pushed  underneath  the 
tendon.  Two  sutures  are  then  introduced  through  the 
tendon,  as  shown  in  Fig.  99,  the  exact  site  being  deter- 
mined by  the  degree  of  advancement  that  is  desired.  If 
the  sutures  are  introduced  as  far  back  as  shown  in  Fig.  99, 
the  tendon  is  divided  at  a  point  slightly  in  front  of  the 
suture  (Landolt  uses  the  scissors  shown  in  Fig.  96),  and 
the  piece  of  tendon  is  then  cut  away  as  far  as  the  insertion 
— that  is  to  say,  the  tendon  is  shortened  by  3  to  5  mm. 
In  order  to  be  able  to  attach  it  in  front,  the  conjunctiva 
and  subconjunctival  tissue  are  then  seized  with  the  con- 
junctival forceps  in  the  direction  of  a  to  6,  and  the  needle 
of  the  corresponding  end  of  suture  is  introduced  as  deeply 
as  possible  through  the  fold  thus  formed,  making  it  pene- 
trate into  the  episcleral  tissue.  The  introduction  of  the 
suture  is  slightly  facilitated  by  the  fact  that  the  conjunctival 
forceps  has  oblique  serrations  wThich  project  beyond  the 


OPERATIONS   OX  TUE   OCULAR  MUSCLES.       253 

point  and  therefore  takes  a  better  hold  on  the  tissues.  If 
it  appear  that  the  suture  has  not  a  deep-enough  hold  on 
the  tissue,  matters  may  be  improved  by  seizing  another 
fold  of  conjunctiva  and  episcleral  tissue  in  a  direction  per- 
pendicular to  a  to  b,  and  again  introducing  the  needle. 
When  these  sutures  have  been  placed,  the  assistant  rotates 
the  bulb  toward  the  side  of  the  muscles  to  be  advanced, 
using  a  fixation-forceps ;  whereupon  the  sutures  are  tied 


Fig.  99.— Advancement  of  the  abdurens  after  Landolt :  The  tendon  has 
been  slightly  raised  with  a  simple  hook.  The  needles  are  later  introduced 
from  a  toward  b  (see  the  text). 


without  any  traction  having  been  made  on  the  tendon  or 
on  the  conjunctival  sutures. 

In  the  following  methods  of  advancement  the  object  is 
to  make  the  approximation  of  the  tendon  to  its  new  place 
of  insertion  somewhat  more  certain  than  in  those  described 
so  far ;  the  sutures  are  not  introduced  blindly,  and  the 
operator  is  not  obliged  to  grope  his  way,  more  or  less,  in 
the  dark  underneath  the  conjunctiva. 

5.  Prince's  operation  is  performed  as  follows  :  A 


254  OPERATIONS  ON  THE  EYE. 

Plate  8. 

Advancement  of  the  right  internus  in  divergent  strabismus,  after 
Prince.  The  suture  in  the  sclera,  to  which  the  tendon  is  afterward  fast- 
ened, is  seen  lying  along  the  corneal  margin.  The  tendon  has  been  seized 
de  with  a  Wecker's  double  hook,  and  the  operator  is  about  to  separate  it 
from  the  sclera. 

suture,  armed  with  a  sharp  needle,  is  introduced  at  the 
corneal  margin,  transfixing  the  conjunctiva,  subconjunctival 
tissue,  and  superficial  layer  of  the  sclera  (see  Plate  8), 
while  the  globe  is  prevented  from  rotating  with  a  broad 
fixation-forceps.  To  this  suture  the  tendon  is  afterward 
attached.  The  latter  is  exposed,  by  means  of  a  vertical 
incision  in  the  conjunctiva,  and  grasped,  either  with  a 
Prince's  forceps  or,  as  shown  in  Plate  8,  with  a  de  Wecker's 
double  hook,  and  divided,  after  which  the  tendon  is  seized 
with  a  suture,  armed  with  two  needles.  Each  of  these 
needles  is  then  introduced  from  below  upward  at  some  point 
on  the  posterior  portion  of  the  globe,  taking  in  tendon, 
capsule,  and  conjunctiva,  one  on  each  side  of  the  median 
line  of  the  tendon  and  about  4  mm.  apart.  One  of  the 
ends  of  the  suture  is  then  laid  square  across  the  cornea,  so 
as  to  cross  the  suture  which  has  been  introduced  at  the 
corneal  margin,  and  which  is  then  tied  over  the  other 
suture  (Fig.  98,  c).  The  other  end  of  the  suture,  which 
passes  through  the  tendon,  is  then  laid  over  the  former  and 
tied,  drawing  the  tendon  and,  with  it,  the  conjunctiva  for- 
ward as  far  as  the  fixation-suture. 

I  have  used  this  method  of  Prince's  almost  exclusively  for  many 
years  whenever  I  have  had  to  do  an  advancement,  and  have  always  had 
good  results  with  it.  Occasionally  I  modify  the  ligation  of  the  sutures 
by  simply  tying  the  two  ends  of  the  suture  which  passes  through  the 
tendon  with  the  two  ends  of  the  fixation-suture,  the  operator  and  the 
assistant  making  uniform  traction  on  the  sutures.  In  this  way  the 
tendon  is  spread  out  a  little  more  as  it  is  drawn  forward. 

6.  In  Verhoeff 'S  operation,  which  results  in  a  very 
strong  attachment,  a  vertical  incision  is  made  in  the  con- 
junctiva at  a  distance  of  3.5  mm.  from  the  cornea;  the 
conjunctiva  is  undermined  as  far  as  the  cornea  ;  the  tendon 
is  sought  for,  divided  from  its  lateral  attachments  with  the 


OPERATIONS   ON  THE  OCULAR  MUSCLES.       255 

capsule,  and  grasped  with  a  Prince's  forceps  (Fig.  98,  c). 
If  necessary,  the  squinting  muscle  may  then  be  tenotomized. 
The  edge  of  the  conjunctiva  remaining  along  the  cornea  is 
dissected  back  as  far  as  the  latter  membrane,  and  a  suture 
with  a  needle  at  each  end  is  then  introduced  vertically  a 
distance  of  6  to  8  mm.  through  the  superficial  layer  of  the 
sclera,  at  a  distance  of  about  1  mm.  from  the  corneal 
margin,  in  the  portion  of  the  sclera  which  has  been  ex- 
posed by  the  dissection.  The  needle  is  to  be  reintroduced 
at  the  point  of  exit  and  carried  a  short  distance  in  a  hori- 
zontal direction.  The  same  thing  is  then  repeated  at  the 
point  of  entrance  with  the  second  needle.  The  two  needles 
having  been  passed  through  the  tendon  at  some  point  be- 
hind the  scleral  side,  the  assistant  grasps  it  with  a  clamp  and 
draws  it  forward  as  far  as  necessary  to  bring  the  desired 
part  on  the  scleral  suture,  which  is  then  tied  (Fig.  98,  e). 
The  piece  of  tendon  contained  within  the  clamp  is  then 
resected,  the  remainder  —  between  the  suture  and  the 
cornea — is  pushed  under  the  conjunctiva,  and  the  mem- 
brane united  over  the  suture.  The  conjunctival  suture 
may  be  remove  after  four  days,  the  one  in  the  tendon  after 
seven  days.  The  needles  used  for  introducing  the  suture 
into  the  sclera  should  not  be  too  long  and  not  too  sharply 
curved  at  the  point.     The  suture  must  not  be  too  thick. 

7.  With  Worth's  method  of  advancement,  that  por- 
tion of  the  suture  with  which  the  tendon  is  seized  is 
secured  as  firmly  as  possible  by  including  the  adjoining 
Tenon's  capsule  along  with  the  tendon  (Fig.  98,/),  access 
having  been  obtained  to  the  insertion  of  the  tendon  through 
a  vertical  incision  in  the  cornea  about  10  mm.  in  length. 
A  Prince's  clamp  is  applied  behind  the  insertion  in  such  a 
way  as  to  include  Tenon's  capsule  and  the  conjunctiva 
over  the  tendon.  After  the  tendon  has  been  divided  from 
the  scleral  side,  it  may  be  raised  sufficiently,  by  means  of 
the  clamp,  to  permit  of  the  introduction  from  within  out- 
ward of  a  suture  through  conjunctiva,  capsule  and  tendon, 
which  is  made  to  emerge  at  b ;  the  other  edge  of  the  tendon 
is  seized  in   the   same  way  and   the   suture  (cd)  is   tied. 


2o6  OPERATIONS  ON  THE  EYE. 

Hence,  one  of  the  sutures  hanging  from  the  knot  is  with- 
out a  needle,  while  the  other  has  one.  The  latter  is  then 
introduced  a  little  behind  the  knot  at  e,  from  without  in- 
ward, and  passing  through  conjunctiva,  capsule  and  tendon, 
carried  forward  underneath  the  tendon  toward  the  cornea, 
and  made  to  emerge  at  g,  after  passing  through  the  edge 
of  conjunctiva  and  the  subconjunctival  tissue.  The  same 
thing  is  done  with  the  suture  at  the  other  edge  of  the 
muscle.  The  two  sutures — that  which  has  been  left  hang- 
ing from  the  knot  in  the  tendon  and  that  which  has  passed 
forward  through  the  limbus  of  the  sclera — are  then  tied. 

Worth  attaches  a  great  deal  of  importance  to  the  quality 
of  the  thread,  which  must  not  be  too  thin,  and  which  he 
prepares  very  carefully  by  drawing  it  through  a  boiling 
mixture  of  beeswax  (3  parts)  and  white  vaselin  (5  parts), 
and  keeps  in  a  sterile  vessel. 

One  sometimes  has  the  unpleasant  experience  in  doing 
an  advancement  of  having  the  suture  cut  through  the 
tendon  or  through  the  conjunctiva  in  front.  Often  the 
tendon  of  a  muscle  which  is  to  be  advanced  is  atrophic, 
thin  and  narrow,  and  does  not  afford  sufficient  hold  for 
the  suture,  especially  when  the  latter  is  merely  passed 
through  the  body  of  it.  The  conjunctiva  and  the  epi- 
scleral tissue  also  may  not  always  be  sufficiently  robust  to 
resist  the  constant  traction  exerted  by  the  muscles  on  the 
suture.  If  the  stitch  cuts  through,  the  result,  unfortu- 
nately, is  that  the  advancement  becomes  converted  into  a 
condition  of  more  or  less  marked  retraction. 

These  considerations  suggested  different  methods  to 
secure  the  same  result  as  were  obtained  by  advancement, 
which  are  :  (1)  making  a  fold  in  the  muscle  or  tendon,  with- 
out separating  the  latter  from  its  insertion  ;  (2)  resection 
and  actual  suturing  of  the  tendon,  thereby  also  effecting  a 
shortening  of  the  tendon  or  of  the  muscle. 

8.  Capsular  Advancement  after  de  Wecker. — 
In  this  operation  the  tendon  is  folded  as  described  above, 
and  Tenon's  capsule  is  drawn  forward.  Since  1888  the 
originator  has  used  this  method  exclusively  instead  of  his 


OPERATIONS  ON  THE  OCULAR  MUSCLES.       257 

muscle  advancement  (described  on  p.  250).  Instead  of  a 
vertical,  a  curved  incision  is  made  about  10  to  12  mm.  in 
length  in  the  conjunctiva,  running  parallel  to  the  cornea 
and  a  few  millimeters  from  its  margin.  When  it  is  de- 
sired to  obtain  a  very  marked  effect,  a  crescentic  piece  of 
conjunctiva  is  excised  by  means  of  a  second  curved  in- 
cision. 

A  vertical  slit,  a  few  millimeters  in  length,  is  then  made 
in  the  capsule,  both  above  and  below  the  tendon  and  in 
the  direct  prolongation  of  the  line  of  insertion.  Through 
these  two  openings  the  capsule,  as  well  as  the  tendon,  is 
undermined  with  closed  scissors,  and  any  adhesions  between 
the  latter  and  the  sclera  are  divided.  Through  these  open- 
ings in  the  capsule  the  sutures  are  then  introduced,  one  of 
the  two  needles  of  a  doubly  armed  suture  being  introduced 
in  the  upper,  and  one  in  the  lower,  opening  and  brought 
out  underneath  the  tendon,  5  to  8  mm.  behind  the  inser- 
tion, transfixing  the  tendon  and  conjunctiva.  The  two 
stitches  should  be  3  mm.  from  the  edge  of  the  tendon  and 
3  mm.  apart.  The  other  needle  is  introduced  into  the 
aforesaid  opening  in  the  capsule  and  carried  forward, 
under  the  conjunctiva,  in  the  superficial  tissue  of  the 
sclera  as  far  as  shown  in  Fig.  98,  b.  The  upper  and  the 
lower  sutures  are  then  tied,  while  at  the  same  time  that 
portion  of  the  tendon  which  is  transfixed  by  the  two  fast- 
enings is  drawn  forward  along  with  the  capsule  and  the 
conjunctiva.  In  other  words,  a  fold  is  made  in  the  tendon, 
since  the  original  insertion  is  retained.  The  operation  is 
in  every  way  analogous  to  de  Wecker' s  method  of  advance- 
ment, which  has  been  mentioned,  except  that  the  tendon 
is  not  separated  from  the  conjunctiva. 

9.  Knapp's  Method. — Knapp  modified  his  method 
of  advancement  (see  p.  249)  in  a  similar  manner — that  is, 
he  introduced  the  sutures  in  almost  the  same  manner,  but 
does  not  separate  the  tendon,  so  that  he  also  makes  a  fold 
in  the  tendon  and  in  the  capsule,  since  the  posterior  por- 
tion of  the  tendon,  which  is  seized  by  the  stitches,  is  drawn 
forward  over  the  insertion. 

17 


258  OPERATIONS  ON  THE  EYE. 

10.  Certain  American  authors  are  even  more  radical  in 
their  efforts  to  bring  about  a  dnplicature  of  the  tendon. 
Thus,  Todd,  for  example,  after  freely  exposing  a  consid- 
erable portion  of  the  tendon  by  means  of  a  flap  incision 
through  conjunctiva  and  capsule,  performs  an  actual  fold- 
ing over  by  means  of  a  fork-shaped  instrument  and  fixes 
the  dnplicature  with  two  catgut  sutures.  The  "  tendon 
folder  "  is  so  constructed  that  the  two  arms  can  be  approx- 
imated by  means  of  a  screw,  and  its  action  may  be  com- 
pared to  that  of  a  two-tined  fork,  one  tine  of  which  would 
be  placed  on  the  tendon  near  the  insertion,  while  the  other 
is  placed  underneath  the  tendon  behind  it.  If  the  fork 
were  turned  about  its  long  axis,  the  posterior  portion  of 
the  tendon  would  come  to  lie  on  the  anterior  portion. 
After  tying  the  two  catgut  sutures,  Todd  further  secures 
the  duplicature  with  two  silk  sutures,  which  include  the 
conjunctival  flap,  and  are  brought  out  in  front,  a  little  to 
one  side  of  the  cornea,  in  a  manner  similar  to  that  em- 
ployed in  de  Wecker' s  advancement. 

11.  Brand  adopted  yet  another  method  of  making  a 
duplicature.  After  freely  exposing  the  tendon  between 
two  ordinary  strabismus-hooks,  he  inserts  a  particularly 
heavy  strabismus-hook  (2  to  2.5  mm.  in  thickness)  under- 
neath the  tendon,  between  the  other  two  hooks,  and  intro- 
duces sutures  underneath  the  large  hook,  so  that  the  tendon 
is  shortened  by  an  amount  equal  to  the  part  that  has  been 
elevated  with  the  large  hook. 

12.  Schweigger's  Method. — Resection  of  a  stretch 
of  tendon  as  long  as  the  necessities  of  the  case  require, 
followed  by  suturing  of  the  ends  is  a  method  that  has 
been  chiefly  cultivated  by  Schweigger.  His  operation  for 
"  advancement "  is  performed  as  follows  :  After  tenotomy 
of  the  squinting  muscle,  the  conjunctiva  is  incised  directly 
over  the  tendon  of  the  antagonist  in  a  line  parallel  to  the 
tendon,  the  incision  being  carried  through  the  tissues  of 
Tenon's  capsule.  An  unprotected  hook,  curved  on  the 
flat,  is  then  pushed  under  the  muscle,  and  the  latter  ele- 
vated.    Tenon's  capsule,  which  is  usually  raised  at  the 


OPERATIONS  ON  THE  OCULAR  MUSCLES.       259 

same  time  at  the  edge  of  the  muscle,  is  first  transfixed 
with  a  hook  and  then  dissected  away  until  the  entire 
tendon  lies  free  on  the  hook.  To  make  sure  of  this,  it  is 
better  to  introduce  a  second  hook  under  the  muscle  in  the 
opposite  direction.  While  one  hook  is  left  under  the 
tendon,  the  other  is  pushed  along  the  muscle  to  the  point 
where  the  sutures  are  to  be  introduced.  Hence  the  tendon 
and  the  muscle  are  completely  laid  bare  for  a  distance  of 
from  3  to  10  mm. 

With  the  aid  of  a  scale,  with  which  the  length  of  the 
piece  to  be  excised  is  determined,  the  catgut  sutures  are 
placed  in  such  a  way  that  one  of  the  needles  is  introduced  at 
the  point  that  has  been  measured,  from  underneath  the  upper 
edge  of  the  muscle,  carried  forward  from  the  posterior  to 
the  anterior  side  and  brought  out  below  the  middle  of  the 
muscle.  The  entire  muscle  is  thus  ligated  and  divided  in 
front  of  the  sutures.  Each  suture  has  two  needles,  the 
second  of  which  is  used  to  fasten  the  divided  muscle  in 
front  to  the  tendinous  insertion  or  to  the  tendon-stump 
that  has  been  left  at  the  insertion.  A  piece  may  be  ex- 
cised from  the  muscle  that  is  to  be  advanced  if  the  muscle 
has  been  ligated  at  some  distance  behind  the  tendon  ;  for 
it  is  not  necessary  to  leave  more  of  the  muscle  on  the 
tendon  than  is  required  to  furnish  a  good  hold  for  the 
suture.  As  a  rule,  the  excision  of  a  piece  of  muscle  is 
unnecessary. 

13.  Kostens  method  of  advancing  the  tendon  is 
quite  similar  to  Schweigger's,  except  that  he  does  not 
divide  it.     He  thus  effects  a  duplicative  of  the  tendon. 

14.  On  the  other  hand,  Iy.  Müller  recommends  actual 
myectomy,  like  the  operation  of  suturing  tendons  per- 
formed by  the  surgeons,  but  accompanied  by  tenotomy  of 
the  squinting  muscle  ;  while  Vieusse  and  Xoyes-(Detroit), 
who  were  the  first  to  practise  excision  of  a  piece  of  the 
tendon,  do  not  correct  the  squinting  muscle.  Müller 
points  out  that  advancement  of  the  muscle  is  a  very  im- 
perfect operation  and  has  no  analogue  in  general  surgery. 
He  says  it  is  impossible  to  tell  how  much  the  movable 


260  OPERATIONS  ON  TUE  EYE. 

conjunctiva  will  yield  to  the  tonic  pull  of  the  distended 
muscle  during  the  hours  immediately  succeeding  the  opera- 
tion, and  that  is  why  the  operator  always  tries  to  get  a 
much  greater  effect  than  he  ultimately  wants,  because  he 
does  not  know  how  much  of  the  primary  effect  will  be 
lost.  He  also  thinks  it  is  very  important  to  leave  the 
insertion  of  the  tendon  in  the  bulb  intact,  so  as  to  avoid 
displacement  of  the  tendinous  insertion  if  the  line  of  union 
turns  out  crooked ;  such  a  dislocation  is  very  easily  pro- 
duced during  the  operation  for  advancement  and  may 
cause  upward  or  downward  deviation  of  the  globe. 

The  operation  should  be  performed  under  anesthesia,  so 
that  the  muscles  may  be  relaxed.  A  vertical  incision  is 
made  in  the  conjunctiva,  4  mm.  from  the  cornea,  and  the 
mucous  membrane  dissected  away  sufficiently  to  leave  the 
muscle  fully  exposed.  A  strabismus-hook  is  then  placed 
underneath  the  muscle,  and  its  lateral  connection  with 
Tenon's  capsule  divided  with  scissors  as  far  back  as  the 
length  of  the  piece  of  muscle  that  is  to  be  excised,  which 
in  divergent  squint  may  be  6  mm.  in  length  and  equiva- 
lent to  the  degree  of  deviation — in  divergent  squint,  1  to 
2  mm.  greater;  and  in  convergent  squint,  1  mm.  less. 
This  length  is  laid  off  on  the  muscle  with  a  pair  of 
dividers,  taking  care  to  leave  a  piece  2  mm.  in  length 
attached  to  the  sclera  in  front.  Behind  the  piece  that  is 
to  be  excised  a  moderately  heavy  silk  suture  is  introduced 
at  the  upper,  and  another  at  the  lower,  edge  of  the  muscle, 
taking  in  about  \,  and  tied  with  a  surgical  knot  to  prevent 
slipping.  Hence,  there  are  two  free  ends  at  the  upper 
and  two  at  the  lower  edge  of  the  muscle  ;  and  of  each 
pair  one  is  cut  off  close  to  the  knot.  The  muscle  is  then 
divided  in  front  of  the  sutures  and  the  anterior  piece 
amputated,  all  but  the  above-mentioned  stump,  which  is 
2  mm.  wide.  Two  corresponding  sutures  are  then  intro- 
duced into  this  stump  in  the  same  way  as  in  the  muscle ; 
and  the  two  upper,  and  then  the  .two  lower,  ones  tied  with 
surgical  knots.  Whenever  the  tension  is  found  to  be  very 
great — when    the   stitches    in    the    tendon   are    brought 


OPERATIONS  ON  THE  OCULAR  MUSCLES.       261 

together — Müller  adds  an  ordinary  tendon-suture,  after 
Wölfler,  through  the  middle  portion  of  the  muscle.  The 
conjunctiva  is  then  closed  over  all  by  means  of  two 
sutures.  The  tendon-muscle  sutures  heal  into  the  wound 
and  are  not  removed.  Both  eyes  must  be  bandaged  for 
three  days. 

Both  operation  and  after-treatment  must  be  conducted 
according  to  aseptic  principles  in  all  these  procedures  of 
advancement,  duplicature  or  resection ;  special  attention 
should  be  given  to  the  sterilization  of  the  suture  material. 
But  no  matter  how  perfect  the  sterilization,  a  suture 
should  never  be  passed  completely  through  the  sclera  to 
the  corneal  margin,  for  after  a  few  days  the  operative  field 
ceases  to  be  sterile,  and  there  is  every  possibility  of  infec- 
tion spreading  along  such  a  suture  into  the  interior  of  the 
globe  and  doing  a  great  deal  of  damage. 

A  good  many  operators  recommend  general  anesthesia 
in  cases  of  advancement.  In  regard  to  this  point  I  adhere 
to  the  opinion  which  I  expressed  emphatically  on  page  27, 
and  I  may  add  that  I  have  performed  a  large  number  of 
advancements  with  nothing  more  than  cocain  anesthesia 
during  the  last  twenty  years,  and  do  not  believe  that  I 
have  had  any  worse  results  by  so  doing. 

An  operation  for  advancement  is  followed  by  a  good 
deal  of  pain,  which  persists  for  several  hours,  and  should 
be  relieved  by  an  injection  of  morphin. 

Another  unpleasant  feature  about  this  operation  on  the 
antagonistic  muscles  is  the  necessitv  of  wearing  a  double 
bandage  for  several  days  to  insure  healing.  In  cases  of 
advancement  such  a  bandage  must  be  worn  for  six  to 
eight  days ;  in  duplicature  or  resection  a  few  days  less. 

The  redness  and  swelling  which  persist  for  some  time 
after  the  advancement  and  duplicature  always  subside  in 
the  end.  On  the  other  hand,  one  can  never  be  certain 
whether  the  sutures  that  have  been  left  will  become 
encysted  or  will  be  extruded  after  a  period  of  weeks  or 
months ;  an  occurrence  which  the  patient  usually  finds 
most  unpleasant. 


262  OPERATIONS  ON  THE  EYE. 

Müller  has  pointed  out  that  the  only  effect  of  advancement  is  to 
shorten  the  muscle ;  for  the  advanced  muscle  probably  grows  fast  to  the 
bulb,  along  the  entire  interval  between  the  side  of  the  wound  and  that 
of  the  old  insertion,  and  does  not  unwrap  itself  from  the  globe  even  in 
extreme  rotation.  Hence,  the  advanced  muscle  is  practically  inserted 
at  the  side  of  the  original  tendinous  insertion. 

Later,  it  was  actually  proved  by  Fröhlich  that  such  is  actually  the 
case.  Five  weeks  after  advancement,  to  a  point  in  front  of  the  original 
(normal)  insertion  of  the  corresponding  advanced  muscle,  he  cut  down 
vertically  as  far  as  the  sclera,  so  that  that  portion  which  had  been 
advanced  beyond  the  original  insertion  was  completely  separated  from 
the  rest  of  the  muscle.  But  the  effect  of  the  operation  was  in  nowise 
impaired,  nor  did  he  find  a  free  space  between  the  advanced  terminal 
portion  of  the  muscle  and  the  globe. 

With  regard  to  the  indications  for  the  different  kinds 
of  operations  performed  for  the  correction  of  strabismus, 
it  may  be  said  that  the  divergence  of  opinion  is  still  very- 
great.  Opinions  differ  widely  even  with  regard  to  the 
age  at  which  they  may  be  undertaken.  As  convergent 
squint  in  children  occasionally  disappears  as  they  grow 
older,  many  operators  maintain  that  no  operation  should 
be  performed  for  the  correction  of  this  variety  of  strabis- 
mus before  the  fourteenth  to  the  sixteenth  year.  Others 
recommend  an  early  one  in  order  that  binocular  vision 
may  be  established  as  soon  as  possible.  There  is  no 
doubt  that  in  cases  of  convergent  squint  in  children  one 
has  to  be  very  careful  not  to  overcorrect  the  error  and 
cause  subsequent  divergent  squint,  which  is  quite  apt  to 
develop  in  cases  of  this  kind,  especially  when  the  tenotomy 
has  been  radical.  Earlier  than  the  fifth  or  the  sixth  year 
surgical  aid  for  the  correction  of  convergent  strabismus  is 
not  to  be  recommended,  in  my  opinion  ;  after  that  year 
one  must  be  guided  by  individual  conditions  and  by  the 
severity  and  character  of  the  anomaly.  In  general  it  may 
be  said  that  the  older  the  patient,  the  more  radical  may 
be  the  treatment.  Especially  in  adults  with  marked  stra- 
bismus no  satisfactory  result  can  be  hoped  for  without 
thorough  advancement. 

In  regard  to  the  choice  of  operation  in  any  given  case 
of  strabismus  there  is  a  similar  difference  of  opinion,  and 
theory  and  practice  are  also  at  variance.     Most  of  the 


OPERATIONS  ON  THE  OCULAR  MUSCLES.       263 

procedures  by  which  the  antagonist  of  the  squinting  mus- 
cle is  corrected  by  advancement,  duplicative  and  the  like, 
and  which  I  have  not  by  any  means  exhausted  in  the 
above  list  of  14,  show  that  the  task  is  not  an  easy  one 
and  that  its  solution  does  not  always  satisfy  the  operator. 
This  is  largely  because  all  the  sutures  have  to  be  intro- 
duced in  soft,  yielding  tissue,  and  cut  through,  more  or 
less,  on  account  of  the  steady  pull  of  the  muscle.  The 
firmer  the  anterior  fixation  of  the  suture,  the  more  will 
the  tendinous  portion  be  endangered  ;  and  vice  versa.  To 
be  moderately  sure  of  a  good  result,  both  eyes  must  be 
completely  immobilized  for  six  or  seven  days,  and  this 
subjection  to  the  discomfort  of  a  double  bandage  is  a  very 
unpleasant  concomitant  of  the  operation.  As  the  pull 
of  the  muscle  is  weakened  by  adding  tenotomy  of  the 
squinting  muscle  to  the  advancement  operation,  the  former 
is  specially  to  be  recommended  whenever  a  marked  degree 
of  strabismus  is  to  be  corrected.  Simple  advancement 
without  tenotomy,  sometimes  on  both  sides,  has  been 
chiefly  recommended  by  Landolt  for  convergent  squint  in 
youthful  individuals.  It  is  quite  conceivable  that  in  this 
way  there  is  less  danger  of  overcorrection,  and  that 
mobility  is  better  than  when  tenotomy  is  performed.  On 
the  other  hand,  I  have  seen  exophthalmos  develop  after 
radical  advancement  without  tenotomy  of  the  squinting 
muscle,  and  the  cosmetic  effect  was  very  bad. 

As  regards  mobility,  it  should  always  be  borne  in  mind 
that  tenotomy  must  be  performed  with  due  caution  and 
in  such  a  way  as  not  to  impair  the  mobility  of  the  globe 
in  the  domain  of  the  tenotomized  muscle ;  hence,  the  lat- 
eral attachments  of  the  tendon  with  the  capsule  must  not 
be  injured.  Too  thorough  correction  should  not  be 
attempted  with  a  single  operation  ;  it  is  better  in  cases  of 
severe  strabismus  to  distribute  the  effect  over  the  two  eyes. 
If  the  squinting  persists,  it  is  not  advisable  to  subject  the 
same  muscle  to  a  second  tenotomy ;  in  such  a  case  one 
should  always  resort  to  advancement. 

It  has  also  been  objected  that  tenotomy  is  followed  by 


264  OPERATIONS   ON  THE  EYE. 

protrusion  of  the  eye  and,  when  the  internus  has  been 
cut,  to  disfiguring  retraction  of  the  inner  canthus.  So  far 
as  the  last-mentioned  disfigurement  is  concerned,  it  can 
be  avoided  by  undermining  the  conjunctiva,  as  far  as  the 
caruncle,  before  doing  the  tenotomy  and  dividing  it  so  as 
to  separate  its  connections  with  the  muscle,  which  may  be 
expected  to  retract  after  it  has  been  cut.  The  conjunc- 
tival wound  must  also  be  carefully  united  after  the  opera- 
tion. If  there  is  staring  of  the  eyeball  after  tenotomy,  it 
is  a  sign  that  the  tendon  has  been  too  freely  separated. 

It  is  very  difficult  to  know  in  advance  how  many 
operations  will  be  required  to  correct  a  case  of  strabismus, 
and  it  is  practically  impossible  to  predict  exactly  what  the 
ultimate  effect  will  be.  This  is  dependent  not  only  upon 
how  much  of  the  tendon  is  separated  from  the  globe,  but 
even  more  on  the  strength  of  the  antagonist  and  its 
ability  to  rotate  the  globe  to  its  own  side.  But  even  with 
the  most  ingenious  method  of  examination  it  is  impossible 
to  predict  what  the  permanent  strength  of  the  antagonist 
will  be,  because  in  all  these  examinations  it  is  only  the 
momentary  contracting  power  of  the  muscle  that  is  tested, 
and  a  tenotomy  or  an  advancement  not  infrequently  in 
the  end  produces  quite  a  different  effect  from  the  one  that 
had  been  expected. 

The  treatment  is  most  successful  when  it  is  conducted 
upon  the  same  lines  as  orthopedic  treatment,  the  correction 
being  kept  up  cautiously  until  a  satisfactory  result  is 
obtained.  The  operator  should  never  allow  himself  to  be 
beguiled  into  making  any  definite  statement  beforehand 
about  the  duration  of  treatment  and  the  kind  and  number 
of  operations  that  will  be  required. 

In  severe  degrees  of  strabismus,  especially  in  the  diver- 
gent form,  in  which  there  is  less  danger  of  overcorrection 
or  of  the  condition  later  changing  to  convergence,  it  is  well 
not  to  separate  too  much  of  the  tendon  from  the  globe, 
and  to  combine  tenotomy  with  advancement,  making  the 
latter  as  radical  as  possible.  In  most  cases  of  convergent, 
as  well  as  divergent,  squint  the  ultimate  effect  is  insufficient, 


ENUCLEATION  OF  THE  GLOBE.  265 

and  the  anomaly  can,  as  a  rule,  be  fairly  well  corrected  by 
means  of  a  tenotomy  on  the  other  eye.  The  operative 
treatment  must  be  combined  with  the  proper  use  of  lenses 
and  stereoscopic  exercises. 

If,  after  tenotomy  and  advancement  have  been  done  on  the  eye,  there 
is  only  a  slight  deviation,  and  it  is  to  be  feared  that  a  second  tenotomy 
might  produce  an  excessive  effect,  especially  in  cases  of  convergent 
squint,  the  primary  operation  may  be  supplemented  by  Verhoeff 's  oper- 
ation for  lengthening  the  tendon,  which  is  only  moderate  in  its  effect. 
In  this  the  tendon  is  lengthened,  by  means  of  incisions,  without  sepa- 
rating it  from  the  globe  (Fig.  100).  Whether  the  result  of  this  process 
is  more  permanent  than  that  produced  by  partial  tenotomies,  which  were 
formerly  proposed  and  carried  out  by  various  authors,  will  have  to  be 
shown  by  future  experience. 


Fig.  100.— Verhoeff' s  operation  for  lengthening  a  tendon. 

While  the  substitution  of  tenotomy  for  advancement 
would  be  a  most  welcome  change,  the  difficulties  in  the 
way  of  its  accomplishment,  especially  in  children,  are  very 
great.  In  any  case  a  tenotomy,  if  undertaken  at  all, 
should  be  performed  in  such  a  way  as  not  to  disturb  the 
mobility  of  the  globe.  The  weaker  the  muscle  the  more 
urgently  is  advancement  indicated.  For  cases  of  paralytic 
squint  it  is  the  most  important  method. 

ENUCLEATION  OF  THE  GLOBE. 

Complete  removal  of  the  eyeball  from  Tenon's  capsule 
was  first  proposed  by  Bonnet,  of  Lyons,  in  1841.  It  is 
based  on  his  anatomic  studies  of  the  connective-tissue 
capsule  of  the  eye,  for  which  reason  Tenon's  capsule  is  also 
known  as  Bonnet's  capsule. 

When  the  eyeball  is  removed  along  with  some  of  the 
appendages  (as,  for  example,  in  the  case  of  a  tumor  of  the 
globe  that  has  ruptured  externally),  the  operation  is  called 
extirpation  of  the  globe.     When  it  is  still  more  com  pre- 


266  OPERATIONS  ON  THE  EYE. 

Figs.  101-105. — Instruments  used  in  enucleation: 
Fig.  101. —  Straight  conjunctival  forceps. 

Fig.  102. — Blunt,  curved  strabismus-scissors;     a  seen  from  the  side. 
Fig.  103.— Strabismus-hook. 

Fig.  104. — Heavy  fixation-forceps  for  seizing  the  globe. 
Fig.  105.— Heavy,   curved  scissors  for  dividing  the  optic  nerve ;     a 
seen  from  the  side. 

hensive  and  affects  the  entire  orbit,  it  is  known  as  exenter- 
ation of  the  orbit. 

In  cases  in  which  the  eyeball  is  greatly  inflamed  or 
adherent  to  its  surroundings  as  a  result  of  former  inflam- 
mation or  of  subconjunctival  injections  of  bichlorid,  the 
preliminary  treatment  for  enucleation  includes  whatever  is 
necessary  as  a  preparation  for  general  anesthesia.  (For  the 
treatment  in  other  cases  the  reader  is  referred  to  page  30.) 

The  instruments  necessary  for  the  operation  will  be  found 
under  Figs.  101-105.  If  Arlt's  operation  is  selected, 
the  strabismus-hook  (Fig.  103)  is  not  necessary ;  while, 
on  the  other  hand,  a  heavy,  straight  pair  of  scissors,  like 
that  shown  in  Fig.  108,  is  required.  Desmarres'  retractors, 
as  shown  on  Plate  9,  are  specially  recommended  to  begin- 
ners, because  an  inexperienced  operator  is  in  great  danger 
of  cutting  the  lids  in  this  operation  ;  but  specula  like  those 
shown  in  Figs.  14  and  33  can  also  be  used. 

Before  beginning,  especially  if  a  general  anesthetic  has 
been  given,  the  operator  must  carefully  notice  once  more 
which  eye  is  to  be  enucleated,  to  guard  against  the  accident 
of  removing  the  wrong  one,  which  has  happened  more 
than  once.  The  mistake  is  specially  apt  to  happen  when 
the  eyes  present  the  same  external  appearance,  as  when 
both  are  normal  so  far  as  external  appearances  go,  or 
equally  inflamed,  as,  for  example,  in  sympathetic  disease. 
Sometimes  the  mistake  is  due  to  the  fact  that  the  operator 
takes  his  position  at  the  patient  \s  head.  Beginners  ought  to 
make  it  a  rule  to  have  the  sound  eye  covered  for  some  time 
before  the  operation  with  an  occlusive  bandage.  [A  mark 
with  an  anilin  pencil  should  be  made  on  the  brow,  over 
the  eye  to  be  removed. — Ed.] 


268  OPERATIONS  ON  THE  EYE. 

Plate  9. 

Enucleation  of  the  eyeball.  The  globe  has  been  rotated  to  the  extreme 
right  aud  the  optic  nerve  is  being  divided  with  the  scissors. 

It  is  hardly  necessary  to  say  that  the  parts  around  the 
eye  and  the  conjunctival  sac  must  first  be  cleansed  and 
the  instruments  boiled.  It  is  not  necessary  to  cut  off  the 
eyelashes  or  shave  the  eyebrow. 

If  the  operation  is  performed  under  local  anesthesia,  a 
strabismus-hook  for  finding  the  muscle  tendons  should  be 
used,  the  operator  proceeding  as  follows  :  In  enucleation 
of  the  right  eye  he  takes  up  his  position  on  the  right  side 
of  the  patient,  who  lies  on  the  operating  table ;  in  case  of 
a  left  enucleation  he  stands  at  the  patient's  head. 

If  the  eye  is  enlarged  from  the  presence  of  a  staphyloma 
or  buphthalmos,  the  external  canthus  is  laid  wide  open  with 
a  pair  of  straight  scissors  (Fig.  108) ;  the  blunt  blade  of 
which  is  inserted  under  the  outer  commissure,  which  is 
then  divided  with  one  or  two  snips  of  the  scissors. 

With  a  pair  of  curved  strabismus-scissors  (Fig.  102) 
the  operator  then  divides  the  cornea  and,  close  to  it,  the 
conjunctiva,  picking  up  the  latter  with  a  straight  conjunc- 
tival forceps  (Fig.  101)  and  slightly  stretching  it,  so  that 
it  retracts ;  it  is  then  divided  and  undermined.  The 
undermining  is  then  continued  around  the  entire  eyeball 
beyond  the  insertion  of  the  muscles  ;  when  there  are  many 
old  adhesions,  this  as  well  as  the  separation  of  the  tendons 
is  often  a  somewhat  troublesome  procedure.  The  four 
straight  ocular  muscles  are  then  divided  in  the  same  way 
as  in  the  operation  for  strabismus,  each  tendon  being  picked 
up  with  the  hook.  In  this  way  the  quadruple  tenotomy 
can  be  performed  without  inflicting  much  damage  and  with- 
out giving  pain  by  pulling  and  twisting  the  globe.  It 
is  best  to  begin  with  the  external  rectus,  then,  after  the 
capsule  has  thus  been  opened,  the  superior  is  attacked  with 
scissors  and  hook ;  next  the  inferior,  and,  finally,  the 
internus,  are  separated  from  the  globe,  the  latter  being 
divided  behind  the  hook — not  between  the  hook  and  the 


ENUCLEATION  OF  THE  GLOBE.  269 

sclera — in  order  to  leave  a  somewhat  longer  stump  (3  to 
4  mm.)  by  which  to  hold  and  abduct  the  eyeball.  For 
the  latter  purpose  the  heavy  fixation-forceps  shown  in 
Fig.  104  is  used,  and  at  this  point  of  the  operation  the 
surgeon  takes  up  the  heavy,  curved  scissors  |  Fig.  105), 
the  better  and  more  surely  to  perform  the  last  act  of  the 
operation.  With  the  globe  in  extreme  outward  rotation, 
the  surrounding  tissues  are  carefully  dissected  away  with 
the  scissors,  and  the  optic  nerve  is  found  by  palpating 
carefully  with  the  closed  scissors.  It  is  very  important  to 
see  that  the  globe  is  accurately  rotated  outward — that  is, 
brought  into  a  position  of  >imple  abduction  without  either 
elevation  or  depression  (Plate  9),  and  if  this  has  been  care- 
fully attend  to  the  optic  nerve  is  found  without  any  trouble. 
The  operator  then  opens  the  scissors  so  that  the  nerve  slips 
between  the  two  blades,  and  cuts  it  off  short  at  the  globe 
with  one  snip.  The  eyeball  at  once  advances,  the  two 
oblique  muscles  are  divided,  and  the  mass  is  gradually 
removed  from  the  orbit. 

In  cases  of  enucleation  for  glioma  of  the  retina  as  long 
a  -tump  as  possible  is  left  in  dividing  the  optic  nerve — 
that  is,  the  scissors  are  carried  away  from  the  globe  and 
the  optic  nerve  divided  farther  back. 

When  the  operation  is  performed,  under  general  anes- 
thesia, it  is  not  so  necessary  to  avoid  pressure  and  traction 
on  the  globe,  and  Arlt's  method  may  be  recommended  on 
account  of  its  simplicity.  When  the  globe  is  held  fast  by 
dense  adhesions,  however,  the  operation  is  somewhat  more 
difficult  ;  it  is  not  to  be  recommended  when  the  globe  is 
soft.  If  the  operator,  as  is  usually  the  case,  handles  the 
scissors  with  the  right  hand,  he  should  stand  to  the  right 
of  the  patient.  In  enucleating  the  right  eye  he  divides 
the  optic  nerve  from  the  nasal  side,  as  shown  in  Plate  9  ; 
and  in  the  case  of  the  left  eye,  from  the  temporal  side. 
In  the  latter  case  the  globe  is,  of  course,  rotated  toward 
the  nasal  side.  With  a  heavy,  straight  fixation-forceps 
(Fig.  104)  the  operator  then  seizes  the  conjunctiva  near 
the  corneal  margin,  in  front  of  the  internus,  on  the  right 


270  OPERATIONS  ON  THE  EYE. 

side,  and  in  front  of  the  abdncens  on  the  left ;  makes  a 
vertical  incision  with  the  heavy  straight  scissors ;  pro- 
longs the  cut  through  the  cornea,  first  downward  and 
then  upward  along  the  cornea,  as  far  as  the  opposite 
border ;  seizes  the  internus  with  the  forceps  in  the  same 
way  as  the  tendon  is  seized  in  Arlt's  method  of  tenotomy 
(in  the  case  of  the  left  eye  the  externus) ;  and  divides  the 
tendon  as  in  a  strabismus  operation,  except  that  the  divi- 
sion is  made  farther  back,  so  as  to  leave  a  stump  of  tendon 
for  the  further  manipulation  of  the  globe.  From  this 
point  the  blunt  blade  of  the  same  (straight)  scissors,  with 
the  edge  directed  forward — that  is,  held  flat  and  close  to 
the  sclera,  is  carried  to  a  point  behind  the  insertion  of  the 
inferior,  where  the  tendon  of  that  muscle  is  divided  close 
to  the  bulb ;  after  which  the  superior  is  divided  in  the 
same  way.  The  globe  is  then  rotated  to  the  left  side,  and 
the  oblique  muscles,  and  finally  the  externus  or  internus, 
are  divided  with  the  same  scissors,  close  to  the  globe. 
When,  owing  to  great  enlargement  of  the  eye — especially 
posterior  enlargement — or  to  a  relatively  deep  position 
of  a  high  nasal  bridge,  the  optic  nerve  is  not  so  accessible, 
a  pair  of  curved  scissors  (Fig.  105)  should  be  used.  The 
same  instrument  should  be  selected  in  cases  of  glioma  of 
the  retina  in  which  the  optic  nerve  must  be  divided 
farther  back  than  1  to  2  mm.  behind  the  sclera. 

Landolt  designed  two  kinds  of  scissors,  curved  both  on 
the  flat  and  over  the  edge,  one  to  the  right  and  one  to  the 
left,  which  can  be  readily  introduced  underneath  the 
tendons.  Landolt  operates  in  the  same  way  as  Arlt,  but 
always  separates  the  externus  first  and  then  the  inferior 
oblique,  after  which  he  always  divides  the  optic  nerve 
from  the  temporal  side. 

In  arteriosclerotic  individuals  the  hemorrhage  during 
and  after  the  operation  may  be  quite  severe,  but  it  never 
requires  ligation  of  the  vessels.  In  most  cases  it  is  well, 
after  thoroughly  washing  out  the  wound  with  cold  bi- 
chlorid  solution,  1  :  5000,  to  lay  cotton  plentifully  on  the 
cavity  when  the  dressing  is  applied,  for  the  purpose  of 


ENUCLEATION  OF  THE  GLOBE.  271 

compression.  If  this  fails  to  arrest  the  hemorrhage,  the 
cavity  must  be  packed  with  cotton,  iodoform  gauze,  or 
even  gauze  saturated  with  adrenalin.  Sometimes  all  that 
is  necessary  is  to  turn  out  the  large  clot  that  forms  after 
the  operation,  after  which  the  hemorrhage  usually  ceases. 

Some  operators  terminate  the  procedure  by  closing  the 
conjunctiva  with  a  tobacco-pouch  suture,  or  they  may 
unite  the  upper  edge  of  the  bulbar  conjunctiva  with  the 
lower,  or  attach  each  muscle  individually  to  the  con- 
junctiva, so  as  to  get  a  more  movable  stump.  I  have  had 
jio  personal  experience  with  these  different  methods.  I 
have  always  seen  the  cases  end  in  normal  recovery  within 
six  to  seven  days  even  without  a  tobacco-pouch  suture, 
and  only  in  very  rare  cases  have  I  seen  a  mass  of  granu- 
lations result. 

In  fact,  the  tendency  to  healing  in  enucleation  is  very 
great,  abnormal  healing  being  quite  rare.  The  patient  is 
usually  in  a  condition  to  be  discharged  in  six  or  seven 
days. 

Incising  or  puncturing  the  globe  during  the  operation 
is  an  error  in  technic  which  must  be  specially  guarded 
against.  To  avoid  puncture  one  should  dispense  with 
sharp  scissors.  The  accident  of  incising  the  globe,  which 
usually  occurs  as  the  optic  nerve  is  divided,  is  to  be  feared 
particularly  in  eyes  that  have  become  soft  from  cyclitis  or 
injury,  and  have  lost  part  of  their  contents.  Hence  it  is 
well  in  such  a  case  to  fill  up  the  eye  before  the  operation 
by  injecting  cocain  (see  p.  15).  Large  traumatic  wounds 
should,  if  possible,  be  allowed  to  close  up  partially  before 
enucleation  in  order  to  increase  the  chances  of  successful 
operation,  because  pressure  on  the  globe  must  be  scrupu- 
lously avoided. 

The  result  may  be  a  failure  if  the  operator,  before 
dividing  the  optic  nerve,  fails  to  rotate  the  globe  properly 
— that  is,  fails  to  keep  it  in  the  plane  which  passes  through 
the  internal  rectus,  external  rectus,  and  the  insertion  of 
the  optic  nerve.  The  latter  is  thereby  displaced  either 
upward  or  downward,  and  the  scissors,  failing  to  find  the 


272  OPERATIONS  ON  THE  EYE. 

optic  nerve,  cut  alongside  and  usually  produce  a  large 
hemorrhage,  which  will  make  an  inexperienced  surgeon 
lose  his  head.  Under  such  circumstances  it  is  best  to 
withdraw  the  scissors,  let  go  of  the  globe  altogether,  then 
take  a  fresh  hold  and  rotate  it  correctly,  when  the  nerve 
may  again  be  attacked  with  the  scissors.  The  introduction 
of  a  retractor  behind  the  globe,  to  displace  it  forward, 
sometimes  proves  dangerous,  and  is  not  to  be  recom- 
mended, because,  although  one  is  less  likely  to  miss  the 
optic  nerve,  it  is  thereby  subjected  to  undue  tension. 
Spoon-shaped  instruments  have  also  been  constructed 
which  are  to  be  pushed  behind  the  globe  to  facilitate  the 
division  of  the  optic  nerve ;  but  these  instruments  can  be 
dispensed  with. 

If  the  outer  commissure  has  not  been  divided,  the  globe 
may  fail  to  emerge  from  the  orbit  even  if  the  optic  nerve 
has  been  properly  cut,  because  the  eyeball  is  too  large  or 
the  palpebral  fissure  too  small.  In  such  a  case  the  com- 
missure must  be  split  secondarily. 

The  indications  for  the  operation  are  : 

1.  Malignant  tumors. 

2.  Injuries  in  which  enucleation  becomes  necessary, 
either  primarily,  on  account  of  the  great  destruction  of 
the  globe ;  or,  secondarily,  because  of  failure  to  heal  and 
the  danger  of  sympathetic  disease  of  the  other  eye.  The 
latter  is  particularly  apt  to  develop  from  retracted  scars  in 
the  ciliary  region  (also  postoperative  scars),  contracted 
globes  with  sensitiveness  to  pressure,  and  slowly  progress- 
ing post-traumatic  or  postoperative  cyclitis. 

3.  Uncontrollable  pain  in  blind  eyes,  especially  from 
glaucoma,  either  primary  or  secondary. 

4.  Staphylomatous  degeneration  of  the  eye. 

5.  Opinions  differ  in  regard  to  panophthalmia  and  acute 
purulent  inflammation  of  the  interior  of  the  eye,  as  death 
from  meningitis  was  formerly  observed  after  enucleating 
in  cases  of  this  kind.  Many  authorities  to  this  day  regard 
the  presence  of  such  inflammatory  conditions  as  a  contra- 
indication, although  the  number  of  those  who  consider  the 


ENUCLEATION  OF  THE  GLOBE.  273 

operation  justifiable  is  increasing.  Personally,  I  have 
always  regarded  both  mere  intra-ocular  suppuration  and 
panophthalmia — that  is,  the  extension  of  the  inflammation 
to  the  tissues  around  the  globe  with  protrusion,  etc.,  as 
indications  for  enucleation,  and  have  operated  on  a  number 
of  cases  of  that  kind  without  any  bad  results.1  Even  in 
these  cases  recovery  is  usually  smooth  and  remarkably 
prompt.  The  operation  is  a  blessing  to  these  unfortunate 
patients,  because  it  not  only  shortens  their  sufferings,  but 
to  a  great  extent,  also,  their  disability.  The  fact  that  I 
have  observed  uninterrupted  recovery  occur  in  many  cases 
of  the  severest  panophthalmia  with  protrusion,  immobility 
of  the  globe,  and  marked  edema  of  the  palpebral  conjunc- 
tiva is  explained  in  part  by  the  modern  treatment  of 
wounds ;  but  it  is,  no  doubt,  due  in  part  to  the  fact  that 
microbes  capable  of  producing  inflammation  (in  these  cases 
they  were  usually  bacilli)  had  settled,  or,  at  least,  were 
demonstrated,  only  in  a  small  portion  of  the  interior  of 
the  eyeball,  as  has  been  proved  by  a  number  of  micro- 
scopic examinations.  The  frightful  inflammation  to  which 
they  give  rise  and  which  spreads  into  the  orbit  was  to  be 
attributed  solely  to  the  spread  of  their  toxins.  Similar 
conditions  may  be  present  in  many  cases  of  this  kind  ; 
and  in  this  connection  the  observation  made  by  Silber- 
schmidt— that  certain  bacilli  belonging  to  the  group  of 
the  hay  bacilli  are  responsible  for  some  cases  of  panoph- 
thalmia— can  only  be  demonstrated  in  the  globe  for  a 
short  time  (they  evidently  die),  although  the  inflammation 
does  not  subside  at  once. 

As  regards  the  antiseptic  precautions  necessary  in  these 
cases,  one  should,  above  all,  guard  against  incising  or 
puncturing  the  globe,  and,  if  there  is  a  large  wound  that 
has  united,  care  must  be  exercised  not  to  reopen  it. 
Thorough  flushing  of  the  cavity,  with  a  bichlorid  solution 
of  1  :  1000,  while  the  wound  is  held  wide  open  with  the 
lid  specula  is  also  indicated.     In  these  cases  a  few  disks 

1  Dr.  C.  Bauer  has  reported  53  cases  from  the  years  1886  to  1900 
{Korrespondenzblatt  f.  Schweizer  Aerzte,  1901,  p.  577.) 

18 


274  OPERATIONS  ON  THE  EYE. 

of  iodoform  and  a  little  iodoform  gauze  should  also  be 
placed  in  the  wound,  and  in  cases  of  intense  panophthal- 
mia, drainage  should  be  provided  by  means  of  a  small 
rubber  tube  or  a  strip  of  iodoform  gauze  inserted  between 
the  lids  and  brought  out  at  the  outer  or  inner  canthus. 
The  lids  are  also  to  be  covered  with  iodoform  gauze,  and 
the  patient,  in  order  to  facilitate  the  escape  of  the  secre- 
tions from  the  orbit,  should  lie  on  the  side  on  which  the 
drainage  tube  or  gauze  strip  emerges. 

It  is  needless  to  say  that  in  all  cases  of  purulent  inflam- 
mation tobacco-pouch  sutures  and  other  kinds  of  sutures 
of  the  conjunctiva  should  be  avoided.  In  my  opinion 
these  methods  of  suturing  are  in  themselves  bad  surgery 
and,  except  in  wounds  in  which  the  asepsis  is  perfect,  un- 
justifiable. 

[It  is  evident  that  suppuration  within  the  globe  should 
not  be  permitted  to  continue  without  interference,  and  the 
surgeon  must  decide  between  enucleation  and  eviscer- 
ation. Although  the  risk  of  meningitis  or  of  a  fatal 
termination  from  any  cause  after  enucleation  for  any 
pathologic  process  within  the  globe  is  exceedingly  rare — 
being  about  1  in  1 600  operations — it  must  be  remembered 
that  in  the  majority  of  cases  the  lethal  issue  has  occurred 
when  the  pathologic  condition  of  the  eyeball  at  the  time 
of  the  enucleation  was  one  of  partial  or  complete  suppu- 
ration. Now,  while  it  was  not  always  possible  to  connect 
the  meningitis  directly  with  the  operation,  in  some  instances 
this  connection  was  definitely  established  ;  hence  the  claims 
of  evisceration  must  be  considered.  See  a  paper  by  the 
editor  on  "  The  Comparative  Value  of  Enucleation  and 
the  Operations  which  have  been  Substituted  for  it. — 
XIII.  International  Congress  of  Medicine,  Paris,  1900. 
Section  on  Ophthalmology. — Ed.] 

Other  operations  have  been  suggested  in  the  place  of 
enucleation,  the  latter  leaving  a  bad  deformity. 

1.  Resection  of  the  optic  nerve  {Neurectomia  Opticociliaris)  was 
suggested  by  Schweigger,  to  take  the  place  of  simple  division  of  the 
optic  nerve,  which  had  been  used  before  his  time.     He  recommended 


ENUCLEATION  OF  THE  GLOBE.  275 

and  adopted  the  following  procedure :  An  incision  is  made  in  the  con- 
junctiva and  Tenon's  capsule,  3  mm.  behind  the  insertion  of  the  right 
internus;  the  muscle  is  exposed,  and  a  blunt  strabismus-hook  (not 
guarded)  curved  on  the  flat,  and  then  another,  are  introduced  under- 
neath the  muscle.  As  the  two  hooks  are  drawn  in  opposite  directions, 
one  of  them  catches  on  the  angle  at  the  insertion  and  rotates  the  eye 
nut  ward,  while  the  other  draws  the  muscle  up  out  of  the  orbit.  Under- 
neath the  second  hook  a  needle,  threaded  with  catgut,  is  passed  through 
muscle  and  conjunctiva,  reinserted  close  to  the  point  of  exit,  and  brought 
back  again  through  conjunctiva  and  muscle.  The  muscle  is  then  divided 
5  mm.  behind  the  insertion,  and  the  suture  is  tied.  A  second  similar 
suture  is  introduced  through  the  tendon  and  conjunctiva  and  tied  at  the 
anterior  extremity  of  the  muscle.  The  wound  is  then  enlarged  in  the 
direction  of  the  superior  and  inferior  recti,  a  small,  sharp  double  hook 
(Fig.  72)  is  inserted  into  the  sclera  as  far  back  as  possible,  and  the  eye 
is  drawn  forward  and  outward.  A  pair  of  flat  scissors  are  then  intro- 
duced along  the  globe  until  the  orbit  is  reached,  the  optic  nerve  is 
sought  for  and  divided  as  near  as  possible  to  the  optic  foramen.  "With 
the  aid  of  the  double  hook  the  posterior  portion  of  the  periphery  of 
the  eye  is  rolled  forward,  and  the  tendon  stump  adherent  to  the  globe 
is  cut  off  close  to  the  scleral  insertion  ;  finally  the  eye  is  replaced  and 
the  wound  is  closed  with  the  sutures  that  have  been  introduced  at  the 
beginning  of  the  operation.  As  a  last  step  the  palpebral  margin  is  also 
closed  with  a  few  silk  sutures.  Three  sutures  are  quite  enough  to  con- 
trol the  bleeding  and  exophthalmos ;  but  if  this  precaution  is  neglected 
the  hemorrhage  may  prove  most  unpleasant.  After  about  four  days 
this  danger  is  obviated  and  the  sutures,  which  by  that  time  have  usually 
cut  through  the  skin  of  the  upper  and  the  lower  lid,  are  removed. 

de  Wecker  simplifies  the  operation  of  resection  by  confining  it  to 
the  optic  nerve,  from  which  he  excises  merely  a  section  from  5  to  6 
mm.  in  length.  He  also  devised  a  hook  for  seizing  the  optic  nerve,  and 
a  pair  of  scissors  with  which  the  nerve  can  be  compressed  after  it  has 
been  divided ;  in  that  way  he  claims  to  diminish  the  hemorrhage. 

Resection,  which  I  have,  so  far,  never  performed  myself,  may  be 
suitable  for  isolated  cases  in  which  one  has  to  contend  with  severe  pain 
accompanied  by  blindness,  as,  for  example,  in  glaucomatous  degenera- 
tion. But  the  method  is  not  a  sure  preventive  of  sympathetic  ophthal- 
mia, for  the  disease  has  been  known  to  occur  even  after  resection  had 
been  performed. 

2.  Exenteration  or  evisceration  of  the  globe  is  another  operation 
that  has  been  recommended  as  a  substitute  for  enucleation,  and  is  quite 
frequently  performed.  The  object  is  to  remove  the  entire  contents  of 
the  globe  through  a  circular  incision  in  the  sclera  behind  the  cornea, 
after  which  the  sclera  is  closed  in  front.  It  is  claimed  that  in  this  way 
a  larger  and  more  movable  stump  is  obtained,  affording  a  better  hold  and 
greater  mobility  for  the  artificial  eye.  Alfr.  Gräfe  and  Bunge  proceed 
as  follows : 

After  thoroughly  disinfecting  the  operative  field,  the  sclera  is  divided 
by  a  circular  incision  immediately  behind  the  cornea,  the  operator  seiz- 
ing the  palpebral  conjunctiva  close  to  the  corneal  margin  to  his  right 


276  OPERATIONS  ON  THE  EYE. 

side  with  conjunctival  forceps,  while  his  assistant  at  the  same  time  grasps 
the  conjunctiva  at  a  point  5  mm.  farther  back,  but  in  the  same  meridian. 
Between  the  two  forceps,  close  to  the  anterior  forceps,  the  sclera  is  then 
carefully  incised,  layer  by  layer,  with  a  broad  scalpel,  until  the  dark 
ciliary  body  appears  in  the  wound.  With  straight  scissors,  the  blades 
of  which  are  not  too  thick,  and  must  be  blunt  at  the  points  (Stevens' 
scissors  shown  in  Fig.  92  are  suitable),  the  incision  is  then  enlarged, 
while  the  sclera  is  held  fast  with  the  two  forceps,  one  blade  of  the  scis- 
sors being  pushed  forward  between  the  ciliary  body  and  the  sclera. 
After  each  snip  of  the  scissors  the  two  forceps  take  a  new  hold  on  the 
sclera  where  the  incision  ends.  After  the  incision  has  thus  been  enlarged 
around  the  upper  half  of  the  cornea,  the  same  thing  is  done  around  the 
lower  half,  keeping  constantly  close  to  the  corneal  margin.  By  means 
of  Bunge's  scoop  the  entire  contents  of  the  globe  is  then  removed,  if 
possible  in  Mo,  and  if  not,  piece  by  piece.  After  the  cavity  of  the  scleral 
cut  has  been  thoroughly  cleansed  by  scraping  with  scissors  and  forceps, 
or  rubbing  with  gauze,  and  has  been  washed  out  with  a  disinfectant,  the 
opening  in  the  scleral  cavity  is  brought  together  with  3  to  5  sutures, 
which  include  the  conjunctiva,  the  wound  being  then  closed  in  a  hori- 
zontal direction  ;  or  a  tobacco-pouch  suture  may  be  introduced. 

The  after-treatment  in  this  operation  is  much  more  distressing  to  the 
patient  than  in  the  case  of  enucleation. 

The  other  eye  should  also  be  bandaged  for  from  two  to  four  days. 
Severe  ciliary  pain  often  develops  and  has  to  be  relieved  with  morphin. 
The  sutures  are  removed  on  the  fifth  day.  In  from  eight  to  ten  days, 
if  everything  goes  well,  recovery  is  complete.  Possible  complications 
are  orbital  cellulitis,  intense  unilateral  headache,  and  slight  febrile 
movements.  Occasionally  the  operation  needs  to  be  followed  by  a  sec- 
ondary enucleation.  If  the  scleral  cavity  fills  with  blood  and  granula- 
tion grow  in  it  afterward,  the  resulting  stump  may  be  primarily  quite 
small,  not  much  larger  than  after  enucleation.  Sometimes  the  stump 
becomes  small  secondarily  because  shrinking  continues  for  months  and 
even  years,  so  that  the  result  is  not  worth  the  trouble  and  distress  to  the 
patient. 

This  consideration  suggested  the  attempt  to  cause  a  spherical  body 
of  glass  (Mules),  celluloid  (Lang),  silver  (Kuhnt),  etc.  [gold-plated 
balls  are  very  satisfactory — Ed.],  to  heal  into  the  scleral  capsule.  The 
same  thing  was  done  by  Frost  and  Lang  after  enucleation,  with  the 
object  of  getting  the  foundation  for  the  artificial  eye  to  heal  into 
Tenon's  capsule.  Unfortunately,  these  balls  of  glass  and  other  materia  Is 
are  usually  extruded  after  a  time. 

Exenteration  is  not  a  suitable  procedure  in  cases  of  malignant  tumor, 
because  one  can  never  be  sure  that  the  inside  of  the  sclera  has  not  been 
attacked.  In  cases  of  purulent  inflammation,  also,  I  do  not  believe  that 
the  procedure  is  sufficiently  radical  to  insure  perfect  removal  of  all  the 
elements  that  are  responsible  for  the  inflammation.  In  fact,  I  consider 
that  this  operation  is  bad  surgery,  because  it  leaves  a  cavity  with  rigid 
walls,  with  a  possibility  of  noxious  material  being  retained  in  it.  Robust 
as  the  sclera  is,  it  nevertheless  consists  of  living  tissue,  and  it  has  been 
shown  by  microscopic  investigations  (S.  Huge)  that  it  is  very  difficult 


ENUCLEATION  OF  THE  GLOBE.  277 

to  render  the  inside  of  the  scleral  cup  absolutely  free  from  cells  or 
microbes.  It  is,  therefore,  doubtful  whether  exenteration  affords  suffi- 
cient protection  against  sympathetic  disease. 

[Professor  Haab's  statement  that  the  artificial  vitreous 
(glass  or  gold  globes)  used  in  Mules'  operation  "  are  usually 
extruded  after  a  time"  would  not  seem  to  be  entirely  sub- 
stantiated by  statistical  information.  In  1900,  before  the 
Thirteenth  International  Congress  of  Ophthalmology,  the 
editor  read  a  paper  in  which  317  operations  of  this  char- 
acter were  analyzed,  and  in  only  17  per  cent,  was  there 
escape  of  the  artificial  vitreous.  In  more  carefully  per- 
formed series  of  similar  operations  this  percentage  is  re- 
duced to  8.  The  operation  should  be  performed  as  fol- 
lows : 

After  general  anesthesia  a  stop  speculum  is  introduced, 
and  the  conjunctiva  dissected  from  the  corneoscleral  at- 
tachment, in  all  directions  to  the  equator  of  the  ball, 
without  disturbing  the  muscles.  The  cornea  and  1  mm. 
of  the  scleral  margin  are  removed  in  the  manner  described 
under  Evisceration.  Next,  the  contents  of  the  globe  are 
emptied  by  any  convenient  method,  a  small  evisceration 
scoop  being  a  satisfactory  instrument.  Great  care  must 
be  taken  to  remove  the  entire  contents,  leaving  a  perfectly 
clean,  white  sclera.  Hemorrhage  is  controlled  by  packing 
the  scleral  cavity  with  sterilized  gauze,  and  by  frequently 
irrigating  it  with  a  tepid  solution  of  bichlorid  of  mercury, 
1  :  5000.  A  glass  or  gold  sphere  of  such  size  that  it  may 
be  introduced  within  the  scleral  cup  without  difficulty  is 
selected,  its  introduction  being  facilitated  by  splitting  the 
sclera  vertically  for  about  4  mm.  at  the  upper  and  lower 
margins  of  the  opening.  The  introduction  of  the  glass 
sphere  is  further  facilitated  by  the  use  of  an  instrument 
specially  devised  by  Mules  for  this  purpose.  The  con- 
cluding steps  of  the  operation  consist  in  stitching  the 
sclera  vertically,  the  conjunctiva  horizontally,  and  apply- 
ing a  full  antiseptic  dressing.  The  greatest  care  should 
be  exercised  to  secure  absolute  asepsis  during  the  opera- 
tion and  at  the  subsequent  dressings.     The  patient  should 


278  OPERATIONS  ON  THE  EYE. 

be  confined  to  bed  for  at  least  four  or  five  days.  Con- 
siderable reaction  and  marked  Chemosis  of  the  conjunctiva 
may  follow.  This  may  be  controlled  by  the  continuous 
application  of  cold,  and  probably  be  avoided  by  not  re- 
moving the  bandage  for  forty-eight  or  even  seventy-two 
hours.  Mules  recommends  that  the  sutures  should  be  of 
catgut ;  the  editor  prefers  silk  sutures. 

Implantation  of  an  artificial  globe  in  Tenon's  capsule 
after  removal  of  the  eyeball  is  performed  as  follows : 

The  eyeball  is  enucleated  in  the  ordinary  manner,  and, 
after  all  bleeding  has  been  checked,  a  gold  or  glass 
sphere  is  inserted  within  Tenon's  capsule.  The  capsule 
and  conjunctiva  are  next  sutured  over  the  artificial  globe 
with  silk,  the  tendons  of  the  ocular  muscles  having  pre- 
viously been  secured  by  one  of  the  methods  described 
under  Enucleation.  The  subsequent  treatment  is  the  same 
as  that  suited  to  Mules'  operation. — Ed.] 

Artificial  Glass  Eyes. 

The  improvement  in  artificial  eyes,  which  was  stimu- 
lated a  few  years  ago  by  Snellen,  has  greatly  diminished 
the  importance  of  the  two  operations  that  are  performed 
instead  of  enucleation,  and  they  are  therefore  even  less 
justifiable  than  they  were  formerly.  The  artificial  eye 
which  had  been  used  until  that  time  consisted  of  a  com- 
paratively thin  glass  shell,  and  was  originally  intended 
only  to  be  worn  over  a  more  or  less  phthisical  globe. 
Snellen  then  induced  the  firm  of  Müller  Söhne,  in  Wies- 
baden, to  manufacture  eyes  consisting  of  a  double  shell, 
which  possess  the  advantage  that  they  fill  out  the  orbital 
cavity  more  completely  and  have  smoother  edges.  After 
much  trouble  the  firm  succeeded  in  turning  out  artificial 
eyes  of  the  proper  form  and  workmanship,  which  they  call 
"  reform-eyes."  One  of  the  great  advantages  is  that  they 
prevent  the  collapse  of  the  upper  lid,  which  occurs  when 
the  old  form  of  artificial  eyes  is  worn,  and  spoils  the  ex- 
pression. Snellen  is  quite  right  in  saying  that  it  is  more 
important   that   an    artificial   eye  should   fill   the  orbital 


OPERATIONS  ON  THE  ORBIT.  27 '9 

cavity  completely  than  that  it  should  have  a  wide  range 
of  movement.  A  great  many  people  hardly  rotate  their 
eyes  at  all  and  get  along  by  moving  the  head.  In  any 
case  it  is  better  to  advise  the  patient  who  is  forced  to  wear 
an  artificial  eye  to  move  his  head  instead  of  his  eyes. 
The  following  rules  should  be  observed  :  It  should  be 
impressed  upon  the  patient  to  get  a  new  glass  eye  at  in- 
tervals of  eighteen  months  to  two  years,  because  the  glass 
becomes  rough  and  may  produce  irritation  and  a  discharge 
of  mucus,  followed  by  cicatrization  and  shrinking  of  the 
cavity,  which  ultimately  contracts  to  such  a  degree  that  it 
becomes  difficult  or  even  impossible  to  wear  the  artificial 
eye.  This  is  particularly  apt  to  happen  with  the  old  style 
with  narrow  edges.  Abrasion  and  cicatrization  may  also 
occur  if  one  has  made  the  mistake  of  wearing  one  too 
large  in  order  to  make  sure  of  completely  filling  the 
cavity.  One  should  never  order  an  artificial  eye  so  large 
that  the  lids  can  not  completely  close  over  it. 

In  the  case  of  phthisis  of  the  eyeball,  the  patient  should 
not  be  allowed  to  use  an  artificial  eye  unless  it  is  perfectly 
comfortable. 

A  glass  eye  should  be  removed  at  night  in  order  to 
prevent  it  from  getting  rough.  It  should  not  be  placed 
in  water,  but  merely  cleansed  and  then  laid  away  dry. 
The  patients  soon  learn  how  to  insert  it :  first  under  the 
upper,  and  then  under  the  lower  lid.  Removal  is  best 
accomplished  by  means  of  a  glass-headed  pin  ;  this  is  in- 
serted under  the  lower  edge  of  the  artificial  eye,  which  is 
then  drawn  forward. 


OPERATIONS   ON   THE   ORBIT. 

Opening  an  abscess  in  the  anterior  portion  of  the  orbit 
is  a  comparatively  simple  operation,  as  the  abscess  usually 
starts  in  the  bone  or  the  periosteum  of  the  orbit  or  in  the 
adjoining  bony  cavities.  A  broad  incision  is  made  as 
close  to  the  bone  as  possible,  taking  care,  above  all,  not  to 
injure  the  levator  palpebral  superioris. 


280  OPERATIONS  ON  THE  EYE. 

When  the  pus  is  in  a  deeper  situation,  as  when  it  has 
its  origin  in  one  of  the  accessory  sinuses  of  the  orbit,  par- 
ticularly the  ethmoidal  and  sphenoidal  cells,  a  so-called 
orbital  phlegmon  often  results.  This  is  a  dangerous  and 
often  a  violent  inflammatory  process,  which  not  only  soon 
destroys  the  optic  nerve  and  the  patient's  eyesight,  but 
may  also  threaten  his  life.  Immediate  operative  relief  is 
imperative.  Free  drainage  must  be  provided  for  the 
inflammatory  products  (edema,  pus,  etc.)  contained  in  the 
orbit,  in  order  to  rescue  the  tissues  from  compression  and 
intoxication.  For  this  purpose  a  large  incision  is  made  at 
that  portion  of  the  orbital  margin  opposite  which  the 
greatest  degree  of  inflammation  and  swelling  is  discovered 
in  the  depths  of  the  tissues — that  is,  for  example,  above 
and  to  the  nasal  side  when  the  protruding  globe  is  dis- 
placed downward  into  the  temporal  side. 

The  patient  is  anesthetized  and  a  curved  incision,  4  to 
5  cm.  in  length,  is  made  directly  over  the  orbital  edge, 
dividing  the  periosteum.  The  latter  is  then  separated 
from  the  bone  with  an  elevator  (Fig.  112)  to  a  depth  of  3 
to  4  cm.  By  keeping  between  the  bone  and  the  perios- 
teum all  danger  of  wounding  the  levator,  the  trochlear 
nerve,  or  the  lacrimal  gland  is  avoided.  Separation  of 
the  periosteum  is  often  followed  by  a  flow  of  pus  from 
below,  or,  if  not,  the  wound  is  held  open  with  hooks  and 
the  periosteum  is  incised  in  the  depths  of  the  orbit  when 
pus  is  suspected.  By  cutting  from  behind  forward  it  is  not 
difficult  to  avoid  the  eye  muscles.  Even  if  no  pus  is 
found,  but  only  inflammatory  edema,  the  incision  does 
good  and  is  absolutely  required  to  preserve  the  integrity 
of  the  optic  nerve.  Afterward  iodoform  gauze  or  a 
drainage  tube  is  introduced  as  far  as  possible  into  the 
wound  to  facilitate  the  escape  of  the  secretions.  At  the 
same  time,  the  diseased  accessory  cavity  which  contains 
the  source  of  the  process  must  be  subjected  to  vigorous 
treatment. 


THE  REMOVAL   OF  TUMORS  FROM  THE  ORBIT    281 


THE  REMOVAL  OF  TUMORS  FROM  THE  ORBIT. 

Tumors  in  the  anterior  portion  of  the  orbit  can  usually 
be  removed  without  much  difficulty  by  a  curved  incision 
running  parallel  to  the  orbital  margin,  or  they  may  be 
peeled  out  or  dissected  out  by  going  in  through  the  con- 
junctiva. Among  such  are  cysts,  which  are  fairly  common 
(see  Atlas  of  External  Diseases  of  the  Eye,  PI.  12,  Fig.  c). 
The  operator  must  be  careful  to  remove  every  portion  of 
the  cyst,  and  this  is  not  always  an  easy  matter,  because  they 
may  extend  far  into  the  depths  of  the  tissue.  It  will  be 
easier  to  remove  the  posterior  portion  without  injuring  the 
globe  and  without  leaving  anything  behind  if  the  cyst  is 
first  incised  at  some  convenient  point  on  the  anterior  wall, 
and  part  of  the  contents  evacuated ;  the  small  incision 
must,  however,  be  closed  with  a  ligature,  so  that  the  poste- 
rior wall  may  still  retain  some  of  its  rigidity. 

Non-encapsulated  angiomata  in  the  anterior  portion  of 
the  orbit  and  often  extending  into  the  lids  are  usually 
congenital  and  of  slow  growth.  These  tumors,  according 
to  Knapp,  may  be  best  extirpated  by  inserting  the  horn 
handle  of  an  ordinary  lid  speculum  (Fig.  17)  into  the 
conjunctival  sac  underneath  the  lid  in  order  to  avoid  a 
profuse  hemorrhage  into  the  operative  field.  The  instru- 
ment is  pushed  back  under  the  tumor  as  far  as  the  wall  of 
the  orbit,  and  the  flow  of  blood  to  the  angioma  is  thus  con- 
trolled by  pressure.  The  tumor  is  turned  out  through  the 
skin,  avoiding  the  levator  palpebrarum  if  the  tumor 
occupies  the  upper  lid.  Small  remnants  that  have  ex- 
tended to  the  skin  of  the  lids  or  as  far  as  the  palpebral 
margin,  or  even  to  the  back  of  the  posterior  surface  of  the 
lid,  may  be  left  behind ;  according  to  Knapp,  they  disappear 
after  the  main  tumor  has  been  removed. 

For  the  removal  of  small  palpebral  angiomata  the  lid- 
clamps  designed  by  Knapp,  Desmarres  or  Snellen  (Figs. 
120,  122,  124)  are  extremely  useful.  With  this  instru- 
ment the  operation  practically  becomes  bloodless. 

Retrobulbar  automata  and  cavernomata  are  extirpated 


282  OPERATIONS  ON  THE  EYE. 

Figs.  106-112. — Instruments  for  Krönlein's  operation  (half-size) : 
Fig.  106.— Scalpel. 

Fig.  107. — Stout  curved  scissors,  after  Cooper. 
Fig.  108. — Heavy  straight  scissors  with  protected  points. 
Fig.  109.— Forceps. 
Figs.  110,  111.— Tenacula. 
Fig.  112.— Elevator. 

in  the  same  way  as  other  retrobulbar  tumors  ;  the  method 
will  be  discussed  later. 

Whenever  the  whole  or  the  greater  part  of  a  tumor 
spreads  out  behind  the  globe,  a  more  radical  operation  is 
required  for  .its  removal.  Up  to  the  time  when  Knapp 
(1874),  and  especially  Krönlein  (1889),  described  their 
methods  of  operation,  retrobulbar  tumors,  with  few  excep- 
tions, were  treated  by  enucleation  of  the  globe. 

If  the  globe  has  been  displaced  far  forward  by  a  tumor 
situated  at  the  back  of  the  orbit  and  frequently  beginning 
in  the  optic  nerve,  especially  a  myxosarcoma  or  fibrosar- 
coma, it  may  be  possible,  on  account  of  the  anterior  dis- 
placement, to  remove  it  from  in  front  without  sacrificing 
the  globe,  after  Knapp's  method ;  but  the  limited  amount 
of  room  and  the  inaccessibility  of  the  tumor  are  distinct 
disadvantages  which  increase  with  the  size  of  the  tumor 
and  the  number  of  adhesions  to  the  surrounding  tissue. 
Krönlein's  operation  permits  much  easier  access  to  the 
operative  field. 

In  Knapp  and  Lagrange's  operation  for  the  removal  of 
retrobulbar  tumors  without  sacrificing  the  globe,  a  method 
which  is  best  adapted  for  the  optic  nerve,  access  is  gained 
to  the  retrobulbar  space  through  a  large  conjunctival 
incision,  either  from  the  nasal  or  from  the  temporal  side, 
depending  on  the  position  of  the  tumor.  If  necessary 
the  extern  us  or  internus,  and  sometimes  a  second  muscle, 
is  divided  after  having  been  secured  with  a  suture,  which 
is  afterward  used  to  unite  the  two  divided  ends.  By  this 
method  the  globe  can  be  drawn  farther  to  one  side,  and 
better  access  is  obtained  to  the  deeper  portions,  so  that  the 
tissues  can  be  dissected  out  with  the  finger  or  the  hollow 


283 


284  OPERATIONS  ON  THE  EYE. 

Figs.  113-116.— Instruments  for  Krönlein's  operation  (half-size) : 
Fig.  113.— Spatula  for  keeping  back  orbital  congestion. 
Fig.  114.— Chisel. 
Fig.  115.— Mallet. 
Fig.  116. — Electric  circular  saw. 

probe  until  the  tumor  is  reached.  At  this  point  a  ligature 
may  be  passed  around  the  posterior  portion  of  the  optic 
nerve  with  an  aneurism-needle  and  the  structure  tied  off; 
the  nerve  is  then  divided  as  close  as  possible  to  the  optic 
foramen,  and  the  tumor  turned  out  after  the  globe  has 
been  turned  completely  around.  Next  the  optic  nerve  is 
cut  off  close  to  the  globe ;  the  latter  is  replaced  ;  and  the 
muscles  and  conjunctiva  are  reunited  by  sutures.  If  pro- 
fuse hemorrhage  from  the  deeper  tissues  takes  place,  an 
attempt  may  be  made  to  control  the  exophthalmos  by 
closing  the  palpebral  fissure. 

It  is  evident  that  under  certain  circumstances  it  may  be 
difficult  with  this  method  to  remove  all  the  posterior 
portion  of  a  tumor  and  leave  a  clean  surface.  Fortunately, 
primary  tumors  of  the  optic  nerve  are  often  benign  myxo- 
sareomata,  which  represent  the  majority  of  all  optic-nerve 
tumors  ;  and,  although  the  posterior  portion  of  such  a 
tumor  may  remain  in  the  optic  canal,  it  will  not  proliferate 
(Salzmann).  In  the  case  of  sarcoma  and  endothelioma 
complete  extirpation  is  unavoidable. 

Krönlein's  Operation. 

This  represents  a  distinct  advance  in  orbital  surgery. 
It  possesses  the  immense  advantage  that  the  operative  field, 
the  retrobulbar  space,  is  much  more  freely  exposed,  so  that 
the  surgeon  can  see  what  he  is  doing,  and  is  therefore  able 
to  operate  without  doing  so  much  harm.  The  instruments 
which  my  colleague,  Krönlein,  uses  for  this  operation  and 
which  I  obtained  from  him  for  the  artist's  use  (and  I  wish 
to  mention  here  that  I  am  also  indebted  to  his  kindly  help 
for  the  authentic  illustrations  on  Plates  10  and  11  as  well 


285 


286 


OPERATIONS  ON  THE  EYE. 


Plate  io. 

Opening  of  the  orbit  after  Krönlein.  The  skin-muscle-bone  flap  has 
been  reflected  forward  and  shows  a  large  portion  of  the  periorbita.  The 
latter  is  then  incised  from  behind  forward,  producing  the  picture  shown 
on  the  next  Plate. 


as  for  Fig.  117),  are  illustrated  in  Figs.  106-116.  Axen- 
feld  lias  devised  for  this  operation  special  blunt  hooks  and 
holders  or  retractors,  in  the  form  of  round  plates  attached 
to  an  angulated  handle,  for  holding  the  orbital  tissues 
apart.     (This  may  be  obtained  from  Windier,  in  Berlin.) 


..... 

Fig.  117.— Skin  incision  (curved  line)  and  bone  incisions  (heavy  lines)  in 
Krönlein's  operation. 

Independently  of  Wagner,  who  suggested  in  1886  that 
it  might  be  advisable  under  certain  circumstances,  espe- 
cially for  the  removal  of  foreign  bodies,  to  make  a  tem- 
porary resection  of  a  wedge-shaped  piece  of  the  orbital 
edge,  Krönlein,  in  the  same  year,  performed  his  first 
operation  of  this  kind,  after  he  had  tried  it  on  a  cadaver 
and  had  developed  a  definite  plan  of  operation. 


THE  REMOVAL   OF  TUMORS  FROM  THE  ORBIT    287 

Technic. — The  operation  is  performed  under  anes- 
thesia. The  eyebrows  and  hair  having  been  shaved  from 
the  entire  temporal  region,  an  assistant  rotates  the  patient's 
head  slightly  toward  the  sound  side,  and  the  operator 
takes  his  position  at  the  patient's  head  or  to  one  side, 
under  lateral  illumination.  The  first  step  of  the  opera- 
tion consists  in  dividing  the  soft  parts  with  a  curved  inci- 
sion, as  shown  in  Fig.  117.  The  incision  begins  above, 
at  the  point  where  the  linea  semicircularis  of  the  frontal 
bone,  which  is  readily  felt,  intersects  a  horizontal  line 
running  1  cm.  above  and  parallel  to  the  supra-orbital 
margin,  and  is  carried  downward  in  a  gentle  curve  along 
the  temporal  edge  of  the  orbit  to  the  level  of  the  upper  edge 
of  the  zygoma,  where  it  makes  a  bend  backward  and  ends 
at  the  center  of  the  zygoma.  The  center  of  the  curved 
incision  bisects  a  horizontal  line  which  connects  the  outer 
canthus  with  the  outer  orbital  margin.  In  this  interme- 
diate portion  the  incision  should  be  carried  down  to  the 
opening,  while  at  the  upper  and  lower  portions  of  the  orbit 
the  knife  should  divide  only  the  skin,  fascia,  and  muscular 
layer.  The  length  of  this  incision  in  adults  should  be 
from  6  to  7  cm.,  and  in  children  two  to  seven  years  old 
about  4  cm.  It  is  important  not  to  make  the  incision  too 
small  and  to  make  it  exactly  as  described  above.  Above 
all  it  should  not  be  near  the  temporal  side,  but  slightly  to 
the  nasal  side  of  the  temporal  margin,  in  order  that  the 
latter  may  remain  well  covered  by  its  soft  parts. 

At  the  central  portion  of  the  skin  incision,  where  it  is 
carried  down  to  the  bone,  a  sharply  bent  elevator  (Fig. 
112)  is  introduced,  and  the  periorbita  is  separated  as  a 
whole  from  the  external  orbital  wall  upward  to  a  point 
about  1  cm.  above  the  zygomatieo-frontal  suture,  down- 
ward to  the  anterior  orbital  fissure,  while  the  depth  should 
carry  it  well  behind  the  zygomatieo-sphenoidal  suture. 
The  point  of  the  elevator  is  then  carried  vertically  down- 
ward as  far  as  the  anterior  orbital  fissure,  in  order  to 
determine  the  point  where  the  open  incisions  presently  to 
be   made  are  to  converge.     The  elevator  should  not  be 


288  OPERATIONS  ON  THE  EYE. 

Plate  ii. 

Opening  the  orbit  after  Krönlein.  After  the  periorbita  has  been 
divided,  the  deeper  tissues  are  dissected  out  so  as  to  bring  the  posterior 
portion  of  the  globe  and  the  optic  nerve  clearly  into  view.  The  large 
wedge  of  bone  that  has  been  chiselled  out  is  also  distinctly  recognizable 
from  its  orbital  side  as  far  as  its  apex. 


introduced  into  the  fissure  with  too  much  force,  so  as  not 
to  injure  the  infra-orbital  nerve.    ■ 

The  bone  incisions  (see  Fig.  117),  which  are  now  in 
order,  must  mobilize  the  piece  of  bone  which  is  to  be  tem- 
porarily removed,  consisting  of  a  wedge,  the  base  of 
which  is  formed  by  the  outer  orbital  margin,  zygomatic 
processes,  frontal  bone,  and  frontal  processes  of  the 
zygoma,  while  the  apex  lies  behind  the  anterior  extremity 
of  the  anterior  orbital  fissure.  The  soft  parts  having 
been  pushed  to  one  side,  and  the  periosteum  divided  down 
to  the  bone  in  the  line  of  the  bone  incision,  the  zygomatic 
process  of  the  frontal  bone  is  cut  through  transversely 
with  the  chisel  above  the  zygomatico-frontal  suture,  which 
is  readily  felt,  or  with  an  electric  circular  saw  (Fig.  116). 
This  bone  incision  must  not  be  placed  too  high,  to  avoid  open- 
ing the  cranial  cavity.  Beginning  at  this  horizontal  upper 
incision  the  bone  is  divided  with  a  sharp  chisel  (in  order 
not  to  splinter  the  bone)  in  a  straight  line  running 
obliquely  through  the  lateral  wall  of  the  orbit  to  the  ele- 
vator, which  is  fixed  in  the  anterior  orbital  fissure — i.  e., 
to  a  point  1  cm.  behind  the  anterior  extremity  of  the  fis- 
sure ;  at  the  same  time  the  orbital  contents  are  gently 
pressed  toward  the  nasal  side  with  the  elevator.  The 
next  step  consists  in  a  horizontal  division  with  a  chisel  or 
a  saw  of  the  frontal  process  of  the  zygoma,  close  to  its 
base ;  this  is  also  continued  into  the  fissure.  The  piece 
of  bone  is  now  movable  and  may  be  reflected  outward 
along  with  the  skin-fascia-muscle  flap  of  the  temporal 
region  far  enough  to  give  free  access  to  the  orbit,  which  is 
still  half-covered  by  the  periorbita  (Plate  10).  The  latter 
must  be  split  from  before  backward  with   the  blunt  scis- 


THE  REMOVAL   OF  TUMORS  FROM  THE   ORBIT.    289 

sors  (Fig.  108),  and  held  apart  with  tenacula  applied 
above  and  below  (Plate  11),  whereby  free  access  to  the 
retrobulbar  -pace  is  obtained.  Superficially  lies  the  right 
external  rectus  muscle,  which,  if  necessary,  is  divided 
near  its  tendinous  insertion,  after  sutures  have  been  intro- 
duced, so  as  to  make  it  possible  to  unite  the  divided  ends. 
Or  the  abducens  may  be  merely  drawn  to  one  side,  and 
the  dissection  continued  along  the  optic  nerve  with 
Cooper's  scissors  (Fig.  107).  As  the  wound  gradually 
becomes  quite  deep,  good  illumination  is  absolutely  neces- 
sary, especially  when  the  operator  has  to  advance  to  the 
apex  of  the  orbital  funnel  or  as  far  as  the  nasal  portion 
of  the  orbit.  During  the  operation  the  globe  may  be 
pushed  slightly  forward  and  inward  with  a  blunt  hook, 
and  the  orbital  fat  pushed  aside  with  the  instruments 
shown  in  Fig.  113,  or  with  Axenfekrs  plates. 

After  the  retrobulbar  operation  has  been  completed,  the 
eye  muscles  that  have  been  divided  are  reunited ;  the 
skin-muscle-bone  flap  replaced ;  the  periosteum  secured 
with  a  few  silk  sutures  ;  and,  finally,  the  soft  parts  are 
carefully  sutured  with  silk.  A  drainage  tube  or  iodoform 
wick  is  placed  in  the  upper  portion  of  the  wound,  but 
can,  as  a  rule,  soon  be  removed.  An  aseptic  and  occlusive 
bandage,  covering  the  entire  eye,  is  applied.  The  globe 
should  be  carefully  covered  by  the  lids,  especially  in  cases 
in  which  the  cornea  i^  anesthetic,  so  that  if  there  is  no 
ptosis  it  may  sometimes  be  advisable  to  close  the  palpebral 
fissure  with  sutures  (Axenfeld),  a  procedure  which  is  also 
valuable  for  controlling  a  postoperative  retrobulbar  hem- 
orrhage (Braunschweig,  Ellinger). 

As  in  many  cases  this  method  has  been  found  to  possess 
the  disadvantage  of  leaving  the  eyeball  with  defective 
power  of  abduction,  it  is  important  in  this  operation  to 
avoid  injuring  the  abducens,  not  only  when  the  periosteum 
is  opened,  but  also  later  on  ;  in  fact,  during  the  entire 
operation  the  tissues  should  be  dissected  away  with  much 
caution,  to  avoid  injuring  the  nerves  and  the  rest  of  the 
orbital  tissues. 

19 


290  OPERATIONS  ON  THE  EYE. 

There  is  no  special  advantage  in  making  the  bone  incisions  with  a 
Gigli  wire  saw  from  within  outward  or  from  behind  forward  (Schuchardt, 
Torek).  My  colleague,  Krönlein,  was  kind  enough  to  tell  me  that  he 
gave  up  this  method  because  the  introduction  of  the  wire  is  not  by  any 
means  such  a  simple  operation,  especially  if,  as  Torek  advises,  the  outer 
orbital  wall  is  first  perforated  for  the  upper  oblique  incision. 

Czermak,  after  experimenting  on  cadavers,  proposed  a  modification 
of  Krönlein's  operation,  having  for  its  object  to  obtain  still  better  access 
to  the  orbit.  He  resected  with  a  chain  saw  not  only  the  outer,  but  also 
a  small  portion  of  the  lower,  wall  of  the  orbit.  Domela-Nieuwenhuis, 
in  his  exhaustive  monograph  on  Krönlein's  operation,  offers  a  criticism 
of  this  procedure,  based  on  careful  tests  performed  by  himself,  and  con- 
cludes that  Czermak's  operation  is  so  complicated  as  to  belong  rather  to 
the  province  of  the  surgeon,  while  Krönlein's  operation  can  easily  be 
performed  by  an  oculist.  Besides,  he  says,  Czermak's  operation,  al- 
though much  more  difficult,  affords  but  little  better  access  to  the  orbital 
cavity  than  is  obtained  by  means  of  Krönlein's  operation ;  and  finally 
it  is  to  be  remembered  that  the  latter  usually  gives  room  enough  if  it  is 
properly  carried  out. 

Another  modification  of  Krönlein's  operation  was  proposed  by 
Parinaud  and  Roche.  In  order  to  avoid  a  scar  near  the  outer  canthus 
of  the  eye,  with  the  possibility  of  distortion  in  that  direction,  they 
made  the  base  of  the  skin-flap  at  the  orbital  edge  and  reflected  it  for- 
ward. From  the  temporal  portion  of  the  eyebrow  a  horizontal  incision 
is  carried  5  cm.  backward,  then  5  cm.  upward,  and  finally  5  cm.  for- 
ward, making  a  four-cornered  flap  which  is  reflected  forward.  The  rest 
of  the  operation  is  the  same  as  Krönlein's.  Although  the  case  reported 
by  the  authors  made  a  good  recovery,  the  nutrition  of  the  bone  is  in 
much  greater  danger  in  this  operation  than  in  Krönlein's,1  since  it  is 
attached  only  by  the  temporal  fascia  and  temporal  muscle. 

Under  the  name  of  malar  orbitotomy  Rollet  recommended  temporal 
incision  of  the  body  of  the  zygoma  and  performed  it  in  a  case  of 
exophthalmos.  He  exposed  the  bone  by  a  curved  incision  along  the 
outer  and  lower  edge  of  the  orbit,  to  which  he  joined  short  incisionsat 
the  upper  and  lower  extremity,  forming  right  angles  with  the  first  in- 
cisions ;  chiselled  through  the  frontal  process,  the  temporal  process  of 
the  zygoma,  and  the  insertion  of  the  latter  in  the  upper  jaw,  after  which 
he  bent  the  zygoma  outward  and  downward  with  the  finger.  Later  the 
bone  is  raised  and  returned  to  its  original  position.2 

Entering  the  orbit  from  above,  as  proposed  by  Cahen  arid  Franke,  is 
a  much  more  difficult  and  complicated  undertaking.  Cahen,  in  an 
operation  for  the  total  extirpation  of  the  supra-orbital  nerve,  chiselled 
away  the  entire  orbital   wall  for  good,  after  he  had  gained  access  by 

1  These  authors  evidently  misunderstood  Krönlein's  method,  for  they 
speak  of  a  vertical  skin  incision  6  to  7  cm.  in  length,  which,  they  imply, 
was  improved  upon  by  Jonnesco's  adding  horizontal  incisions. 

2  Rollet  also  is  not  sufficiently  acquainted  with  Krönlein's  procedure  ; 
as  appears  from  his  criticism  that  it  involves  fracture  of  the  outer  orbital 
wall,  which  might  extend  into  the  sphenoidal  bone. 


THE  REMOVAL   OF  TUMORS  FROM  THE  ORBIT.    291 

temporary  resection  of  a  piece  of  the  frontal  bone  and  pushed  the  dura 
mater  aside  with  the  bone.  Cahen  believes  this  method  to  be  suitable 
for  regular  orbital  operations.  Franke,  after  experiments  on  cadavers, 
proposed  to  expose  the  upper  portion  of  the  orbit  by  temporarily 
resecting  the  upper  edge  of  the  cavity  and  reflecting  it  downward 
along  with  the  skin.  In  this  way,  he  says,  it  is  possible  to  reach  the 
optic  foramen. 

The  two  methods  devised  by  Gussenbauer,  and  consisting  in  tem- 
porary resection  of  the  framework  of  the  nose,  to  expose  the  two  orbital 
cavities,  and  the  frontal,  ethmoidal  and  sphenoidal  sinuses,  sometimes 
on  both  sides  of  the  head,  may  be  tried  in  orbital  cases  with  simul- 
taneous diseases  of  the  ethmoidal  and  sphenoidal  cavities,  especially  in 
the  presence  of  bilateral  retrobulbar  disease. 

The  operations  of  the  three  latter-named  authors  are  very  much 
more  complicated  than  that  of  Krönlein,  and  in  my  opinion  belong  to 
the  province  of  the  general  surgeon. 

It  appears  from  Domela's  comprehensive  collection  of 
cases,  and  other  contributions  to  the  literature  that  have 
appeared  since  then,  that  the  indications  for  Krönlein's 
operation  are:  1.  Cyst,  particularly  retrobulbar  cyst,  in- 
cluding echinococci  and  cysticerci  (the  latter  are  rarely 
found  in  the  orbit).  2.  Tumors  of  the  optic  nerve  and  of 
its  sheath.  3.  Retrobulbar  cavernous  angioma,  lymph- 
angioma, and  other  retrobulbar  tumors,  also  aneurisms, 
and  varicose  dilations  of  the  orbital  veins.  4.  Retro- 
bulbar injuries,  particularly  foreign  bodies  in  the  orbit. 
5.  Orbital  abscesses  (phlegmon).  6.  Any  operations  on 
the  deeper  portions  of  the  eyes  (removal  of  a  subretinal 
Cysticercus  in  the  macular  region,  opening  the  sheath  of 
the  optic  nerve  in  choked  disk,  Midler's  operation  for 
retinal  detachment,  etc.).  7.  Finally  the  operation  is  also 
perfectly  justifiable  for  purposes  of  diagnosis  in  doubtful 
cases  (Franke,  Braunschweig),  because  it  is  absolutely  free 
from  danger,  and  is  often  the  only  means  of  arriving  at 
an  accurate  diagnosis  of  a  retrobulbar  process. 

Exenteration  of  the  Orbit. 

The  object  in  evacuation  of  the  orbital  cavity  is  to 
remove  not  only  the  globe,  but  all  the  remaining  contents 
of  the  orbit,  as  completely  as  possible.  It  is  usually 
necessitated  by  malignant  tumors,  be  it  that  a  neoplasm 


292  OPERATIONS  ON  THE  EYE. 

has  advanced  from  the  interior  of  the  globe  into  the  orbit, 
or  that  the  latter  is  the  primary  site  of  the  sarcoma,  etc. 
Exenteration  may  sometimes  have  to  be  performed  after 
enucleation  if,  after  the  globe  has  been  removed,  it  is 
found  to  be  ruptured  and  permits  portions  of  the  tumor 
(sarcoma  or  glioma)  to  escape ;  the  perforation  may  be 
quite  small. 

This  operation  also  requires  a  general  anesthetic.  The 
first  step  consists  in  dividing  the  outer  angle  of  the  lid  in 
a  line  coinciding  with  the  prolongation  of  the  palpebral 
fissure,  with  heavy  straight  scissors  (Fig.  108),  carrying 
the  incision  a  good  centimeter  beyond  the  edge  of  the 
orbit.  Beginning  at  the  outer  orbital  edge,  which  has 
thus  been  exposed,  an  incision  is  made  through  the  soft 
parts  around  the  orbital  cavity  from  the  conjunctival  sac 
to  the  bone,  the  lids  being  held  well  apart  with  retractors. 
This  incision  is  made  with  the  scalpel  (Fig.  106),  which 
must  be  kept  close  to  the  orbital  margin.  As  this  incision 
at  the  same  time  divides  the  periosteum  along  the  edge  of 
the  cavity,  it  is  usually  easy  by  means  of  the  elevator 
(Fig.  112),  which  is  introduced  at  the  outer  angle  between 
the  orbital  margin  and  the  periosteum,  to  separate  the 
periosteum  from  the  bone  in  every  portion  of  the  orbit, 
passing  carefully  over  the  thin  parts  of  the  bone,  particu- 
larly the  inner  orbital  wall  (lamina  papyracea  of  the 
ethmoidal  bone,  and  lacrimal  bone),  so  as  not  to  perforate 
the  bone.  Wherever  the  elevator  meets  with  greater  re- 
sistance the  tissues  are  divided  with  the  scissors.  The 
attachment  of  the  posterior  limb  of  the  inner  palpebral 
ligament  and  the  capsular  tag  of  the  internal  rectus,  par- 
ticularly, will  have  to  be  divided  with  the  scissors. 

After  the  periorbita  has  thus  been  removed  from  the 
entire  orbital  funnel  as  far  as  the  apex,  so  that  the  wedge- 
shaped  contents  of  the  cavity  are  held  merely  by  the 
pedicle  formed  by  the  optic  and  remaining  nerves,  the 
blood-vessels,  the  insertions  of  the  muscles,  and  the 
periosteum,  these  tissues  are  divided  with  large  Cooper 
scissors  (Fig.  105),  which  are  introduced  along  the  outer 


THE  REMOVAL  OF  TUMORS  FROM  THE  ORBIT.    293 

orbital  wall.  In  this  way  the  entire  contents,  surrounded 
on  all  sides  by  periosteum,  can  be  removed.  The  hemor- 
rhage from  the  large  orbital  vessels  which  follows  can,  as 
a  rule,  be  controlled  by  packing  with  iodoform  gauze ;  if 
it  is  very  profuse  the  place  may  be  cauterized  with  a 
Paquelin  cautery.  The  cavity  should  be  packed  with  a 
long  strip  of  iodoform,  which  can  afterward  be  removed 
gradually,  a  piece  at  a  time.  In  any  case  the  iodoform 
gauze  must  project  in  front  between  the  lids,  which  are 
not  closed,  and  must  communicate  with  the  gauze  in  the 
dressing,  so  as  to  enable  the  secretions  to  escape  from  the 
cavity.  Czermak  suggests  that  the  entire  orbital  cavity 
be  filled  with  a  large  round  piece  of  iodoform  gauze,  to 
the  center  of  which  a  ligature  has  been  attached ;  this  is 
stuffed  into  the  cavity  like  a  pocket  and  filled  with  strips 
of  iodoform  gauze,  some  of  the  latter  remaining  between 
the  lids,  which  are  held  open.  In  the  cavity  the  gauze 
should  not  be  packed  too  tightly.  When  the  dressing  is 
changed  the  contents  of  the  pocket  are  removed  before 
the  latter  is  withdrawn  by  means  of  the  suture  attached 
to  its  center. 

Since,  after  exenteration  of  the  orbit,  the  lids  retract 
into  the  orbit  as  healing  takes  place,  it  is  impossible  to 
wear  a  false  eye  after  this  operation.  It  is  therefore 
necessary  to  do  something  to  correct  the  ugly  deformity 
which  would  be  produced  by  an  empty  orbital  cavity. 
The  indication  for  this  is  particularly  strong  when  one  or 
the  other  of  the  lids,  or  both,  have  been  removed  at  the 
operation  because  they  are  involved  in  the  neoplasm. 

Another  reason  for  covering  the  large  wound  in  the  case 
assumed  is  that  the  period  of  healing  is  greatly  shortened 
by  such  a  procedure.  If  both  lids  have  been  removed  at 
the  operation,  or  if,  as  in  the  case  shown  in  Plate  12,  they 
have  been  destroyed  by  the  neoplasm  (carcinoma),  the 
procedure  which  was  customary  in  von  Langenbeck's 
clinic  (Krönlein,  namely,  covering  the  defect  with  a  large 
skin  flap  obtained  from  the  neighborhood,  as,  for  example, 
the  forehead,  will  give  the  best  results.     The  skin  flap 


294  OPERATIONS  ON  THE  EYE. 

Plate  12. 

Destruction  of  the  orbit  by  Carcinoma  (rodent  ulcer).  Destruction  of 
the  lids  and  globe,  leaving  only  a  small,  roundish,  shrunken  remainder 
in  the  large  cavity,  the  deepest  portion  of  which  communicates  with  the 
ethmoidal  cells  (dark  spot  in  the  picture),  and  laterally  with  the  nasal 
cavity.  It  is  probable  that  the  carcinoma  started  in  the  lids.  The  result, 
after  extirpation  of  the  neoplasm,  which  was  performed  by  my  colleague, 
Krönlein,  is  seen  in  Figure  118  (p.  296). 

required  for  occluding  the  exenterated  orbit  must  have  a 
pedicle,  and  may  be  obtained,  depending  on  the  necessities 
of  the  individual  case,  either  from  the  skin  of  the  cheek, 
as  in  the  two  cases  cited  by  Krönlein,  or  from  the 
skin  over  the  temporal  and  frontal  regions.  (Information 
kindly  imparted  to  me  by  my  colleague,  Krönlein.)  Küs- 
ter also  recommended  covering  the  wound.  The  operation 
may  be  performed  as  shown  in  Figure  118,  which  repre- 
sents a  picture  of  the  woman,  taken  eight  weeks  after  the 
operation  by  my  colleague,  Krönlein,  for  a  carcinoma 
which  had  penetrated  far  into  the  orbit,  as  shown  in  Plate 
12.  The  entire  cavity  of  the  wound  was  closed  with  a 
large  flap  taken  from  the  forehead,  the  edges  of  the  flap 
being  carefully  united  to  the  edges  of  the  large  wound 
with  sutures ;  after  which  the  denuded  area  in  the  fore- 
head was  at  once  covered  with  skin  grafts,  after  the 
Thiersch  method.  Both  the  latter,  as  well  as  the  large 
pedunculated  flap,  healed  perfectly,  nor  was  there  much 
retraction  later,  because  the  orbit  became  filled  with  a 
thick,  fibrous  tissue,  formed  by  proliferating  granulations. 
When  exenteration  of  the  orbit  is  performed  without 
sacrificing  the  lids,  Küster' s  suggestion  may  be  adopted, 
and  more  rapid  healing  induced  by  freshening  up  the 
edges  of  the  lids  and  uniting  them  with  sutures.  The 
follicles  of  the  lashes  and  the  entire  conjunctiva  are  re- 
moved, and  the  palpebral  fissure  is  closed  with  sutures, 
all  but  one-quarter  for  the  escape  of  the  iodoform  tampon 
with  which  the  cavity  is  filled,  and  which,  after  a  few 
days,  can  be  replaced  by  a  short  drainage  tube.  A  light- 
pressure  bandage  is  then  applied,  and  if  no  infection  takes 


I 


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OPERATIONS  ON  LWS  ÄND   CONJUNCTIVAL  SAC.    295 

place,  complete  healing  occurs  within  one  to  two  weeks, 
although  the  united  lids  become  somewhat  retracted,  but 
only  form  a  shallow  depression.  If  one  eyelid  has  been 
sacrificed,  the  remaining  one  is  utilized  in  the  manner  de- 
scribed above  to  cover  the  cavity  with  a  skin  flap. 

It  has  also  been  advised  to  line  the  entire  cavity  with 
skin  grafts,  after  the  Thiersch  method,  after  exenteration 
of  the  orbit  without  sacrificing  the  lids. 

C.  OPERATIONS   ON   THE    LIDS   AND   IN   THE 
CONJUNCTIVAL    SAC. 

I.  OPERATION   FOR  PTOSIS. 

Ptosis  may  be  congenital  (usually  bilateral)  or  acquired, 
and  in  the  latter  case  it  may  be  unilateral  or  bilateral,  from 
paralysis  of  the  nerves  (oculomotor  or  sympathetic),  or 
from  muscular  anomalies  from  disease  or  after  an  injury. 

The  operative  procedures  vary  according  to  the  cause 
and  character  of  the  ptosis.  If,  as  is  often  the  case  in  the 
congenital  form,  the  levator  is  practically  inactive  or  en- 
tirely absent,  either  functionally  or  structurally,  an  effort 
must  be  made  to  secure  elevation  of  the  lid  through  other 
muscles,  either  of  the  occipitofrontalis  or  the  superior  rec- 
tus of  the  eyeball.  People  with  ptosis,  as  a  rule,  use  the 
frontal  muscle  of  their  own  accord  for  drawing  the  lid 
upward,  and  therefore  present  the  characteristic  deep 
wrinkles  in  the  brow  (see  my  Atlas  on  External  Diseases 
of  the  Eye,  Plate  9).  If  the  ptosis  is  very  great,  such 
patients  also  find  themselves  obliged  to  throw  the  head 
backward,  so  as  to  bring  the  pupil  into  the  palpebral  fis- 
sure. 

To  determine  what  part  in  the  elevation  of  the  eye  is 
played  by  the  frontal  muscle  in  a  patient  of  this  kind, 
pressure  should  be  made  with  the  flat  of  the  hand  on  the 
forehead,  which  causes  him  to  close  the  eyes.  He  is  then 
requested  to  open  the  eyes  wide  and  look  straight  ahead 
or  slightly  upward.     As  the  action  of  the  frontal  muscle 


296 


OPERATIONS  ON  THE  EYE. 


is  then  excluded  by  the  operator's  hand,  any  elevation  of 
the  lid  that  takes  place  must  be  effected  by  the  levator. 


Fig.  118.— This  is  the  same  patient  as  the  one  shown  in  Plate  12.  The  large 
wound  cavity  remaining  after  the  operation  is  here  seen  to  be  covered  with 
pedunculated  flaps  taken  from  the  forehead,  while  the  wound  in  the  forehead 
has  been  covered  with  flaps,  after  the  method  of  Thiersch.  The  operation 
was  performed  by  Krönlein.  This  picture  was  taken  eight  weeks  after  the 
operation. 


There  are  a  number  of  operations  having  for  their  object 
to  increase  the  elevation  of  the  lid  in  ptosis  by  means  of 
the  frontal  muscle,  chiefly  bv  means  of  cicatricial  bands 


OPERATIONS  ON  LIDS  AND  CONJUNCTIVAL  SAC    297 

attaching  the  upper  border  of  the  lid  to  the  region  of  the 
eyebrow.     Among  these  operations  are  : 

1.  Pagenstecher's  Ptosis  Operation. — This  is  per- 
formed with  either  one  or  two  sutures,  each  of  which  is 
armed  with  two  needles.  One  needle  is  introduced  under 
the  skin  of  the  upper  lid,  at  a  point  1  to  2  mm.  from  the 
palpebral  margin,  and  running  parallel  with  it ;  it  is  then 
reinserted  exactly  at  the  point  of  exit,  and  carried  upward 
between  the  tarsus  and  the  skin  of  the  lid  and  brought 
out  above  the  eyebrow  (Plate  13,  Fig.  1).  The  second 
needle  is  then  introduced  at  the  same  point  as  the  first, 
and  also  carried  upward  and  brought  out  alongside  of  the 
suture  of  the  other  needle,  above  the  eyebrow — after  which 
the  two  sutures  are  tied.  The  suture  is  therefore  entirely 
subcutaneous,  and,  if  desired,  a  second  one  may  be  intro- 
duced. The  sutures  are  allowed  to  remain  in  place  for  a 
variable  length  of  time,  and  may  be  gradually  pulled  out 
and  retied  until  they  cut  through  the  tissue,  thus  increasing 
the  scar-formation. 

2.  de  Wecker' s  Operation. — de  Wecker  combined 
the  old  ptosis  operation  by  von  Gräfe  (excision  of  a  semi- 
lunar piece  of  skin  with  the  underlying  orbicularis  muscle 
from  the  upper  lid)  with  Pagenstecher' s  suture.  Hence, 
by  mentally  supplying  this  excision,  Plate  13,  Fig.  1  may 
be  taken  as  an  illustration  of  de  Wecker' s  operation. 

The  object  in  excising  the  orbicularis  muscle  in  von 
Gräfe's  and  de  Wecker' s  operation  is  to  weaken  the  antag- 
onist of  the  levator.  In  cases  in  which  the  upper  lid  is 
thickened  after  trauma,  inflammation,  etc.,  excision  of  the 
skin  also  has  the  advantage  of  diminishing  the  weight  of 
the  lid  and  thus  making  it  easier  for  the  frontal  muscle  to 
elevate  the  lid,  because  it  is  less  apt  to  elevate  only  the 
yielding  skin  instead  of  the  lid  itself. 

3.  Dransart  has  advised  an  operation  similar  to  that 
of  Pagenstecher's,  except  that  his  suture  does  not  extend 
as  far  as  the  edge  of  the  lid,  but  only  as  far  as  the  upper 
border  of  the  tarsus.  He  also  brings  his  three  sutures, 
each  of  which  is  armed  with  two  needles,  out  above  the 


298  OPERATIONS  ON  THE  EYE. 

Figs.  119-124. — Instruments  for  operations  on  the  lid  : 
Fig.  119.— Beer's  knife. 
Fig.  120. — Knapp' s  lid  clamp. 
Fig.  121. — Jäger's  horn  plate. 
Fig.  122. — Desmarres'  clamp. 
Fig.  123.— Wilder' s  double  knife. 
Fig.  124.— Snellen's  lid  clamp. 

eyebrow  and  ties  them  there.  The  short  horizontal  por- 
tion of  the  suture  within  the  lid  passes  through  the  upper 
part  of  the  tarsus  (instead  of  through  the  skin  of  the  pal- 
pebral margin,  as  in  Pagenstecher's  operation).  By 
drawing  the  sutures  more  or  less  tightly  the  effect  can  be 
increased  or  diminished  at  will. 

4.  The  operation  of  Hess  is  a  marked  improvement 
on  that  of  Dransart.  The  eyebrow  having  been  shaved, 
an  incision  is  made  running  the  entire  length  of  the  brow 
through  the  skin  and  the  subcutaneous  tissue.  Through 
this  incision  the  skin  of  the  eyelid  is  dissected  away  from 
the  subjacent  layer  of  orbicularis  muscle  with  a  scalpel. 
After  the  hemorrhage,  which  is  usually  not  marked,  has 
been  controlled,  three  sutures  with  two  needles  each  are 
introduced  from  without  inward  through  the  upper  por- 
tion of  the  dissected  skin  of  the  lid,  so  that  when  the 
sutures  are  drawn  tight  they  form  a  fold  in  the  skin, 
resembling  as  nearly  as  possible  a  corresponding  fold  in 
the  normal  eye.  The  sutures  are  carried  upward  under- 
neath the  skin,  somewhat  as  shown  in  Plate  13,  Fig.  1, 
and  the  needles  are  brought  out  above  the  incision  ;  that 
is,  at  about  the  same  point  as  in  Pagenstecher' s  operation. 
There  they  are  tied,  and  then  allowed  to  remain  in  place 
for  from  a  week  to  ten  days.  If  necessary,  they  may  be 
tightened  from  time  to  time.  The  wound  in  the  eyebrow 
is  closed  with  a  continuous  suture.  The  important  feat- 
ure of  the  operation  is  the  formation  of  an  extensive 
wound  surface,  the  cicatrization  of  which  permanently 
fixes  the  artificial  fold  in  the  upper  lid.  Another  feature 
is  that  the  sutures  are  carried  upward,  bringing  the  upper 
dome  of  the  fold,  which  also  belongs  to  the  wound  sur- 


" 


119 


300  OPERATIONS  ON  THE  EYE. 

Plate  13. 

Fig.  1. — Pagenstecher' s  ptosis  operation  in  a  young  girl  with  congeni- 
tal ptosis. 

Fig.  2. — Gaillard's  suture  in  an  old  man  with  spastic  entropion. 

face,  into  intimate  union  with  the  lower  extremities  of  the 
muscle  bundles  of  the  frontal  muscle,  and  thus  enabling 
the  latter  to  transfer  much  of  its  action  to  the  lid. 

5.  In  Panas'  operation  the  lid  is  fastened  to  the 
frontal  muscle  by  forming  a  skin  flap  about  8  mm.  wide 
and  5  to  6  mm.  high  in  the  lid,  undermining  it  carefully 
and  directing  it  upward.  This  flap  is  then  drawn  up 
under  the  skin  covering  the  region  of  the  eyebrows.  For 
this  purpose  a  horizontal  incision  3  mm.  long  is  made 
immediately  above  the  eyebrow  and  parallel  with  it ; 
through  this  incision  the  skin  between  the  eyebrow  and 
eyelid  is  undermined,  so  that  the  lid  flap  can  be  drawn 
under  this  bridge  of  skin  with  sutures  and  fastened  in 
place.  The  operation  is  very  effective,  but  leaves  unsightly 
scars  in  the  upper  portion  of  the  lid. 

6.  Motais*  Operation. — Instead  of  the  frontal  mus- 
cle, the  rectus  superior  may  also  be  utilized  to  assist  in 
the  elevation  of  the  upper  lid.  This  very  useful  and 
original  operation  of  Motais  is  particularly  adapted  to 
cases  of  ptosis  (especially  bilateral  cases),  in  which  the 
levator  muscle  is  entirely  wanting.  To  secure  good 
access  to  the  operative  field,  the  eye  is  first  rotated  down- 
ward with  the  single  or  double  hooks,  and  the  upper  lid, 
after  being  everted,  is  drawn  upward  (Fig.  125).  Liga- 
tures may  be  used  instead  of  hooks.  A  horizontal  inci- 
sion is  then  made  in  the  bulbar  conjunctiva  and  in  Tenon's 
capsule,  and  the  tendon  of  the  superior  rectus  searched 
for.  A  tongue  is  then  excised  from  the  middle  of  the 
tendon,  running  as  far  as  the  insertion.  A  suture  with 
two  needles  is  passed  through  this  tongue  (Fig.  126), 
which  is  then,  by  means  of  this  suture,  inserted  between 
the  tarsus  and  the  skin  of  the  upper  lid.  For  that  pur- 
pose an  opening  is  made  with  the  scissors  in  the  conjunc- 


er*  '*x8jhj 


OPERATIONS  ON  LIDS  AND   CONJUNCTIVAL  SAC.    301 
Fig.  125.  Fig.  127. 


Fig.  126.  Fig.  128. 

Figs.  125-128.— Motais'  ptosis  operation  (see  text). 

tiva,  and  in  the  levator  tendon  at  the  posterior  extremity 
of  the  inverted  lid  ;  that  is,  at  the  upper  border  of  the 
tarsus   (Fig.    127).     Through   this   opening   a  pouch   is 


302  OPERATIONS  ON  THE  EYE. 

made  between  the  tarsus  and  the  orbicularis  muscle, 
extending  to  within  2  mm.  of  the  edge  of  the  lid,  into 
which  the  suture  with  the  two  needles,  and  bringing  with 
it  the  tongue-like  piece  of  tendon  from  the  superior  rectus, 
is  introduced  (Fig.  128).  The  two  needles  are  then 
brought  out  through  the  tarsus  and  the  skin,  at  a  distance 
of  4  mm.  from  one  another,  and  the  sutures  tied  on  the 
outer  side  of  the  lid.  Thus  the  tongue  of  tendon  lies  on 
the  outer  side  of  the  upper  tarsus.  Postoperative  depression 
of  the  eyeball,  with  corresponding  vertical  diplopia,  which 
sometimes  follows  the  operation,  has  always  disappeared 
after  a  period  varying  from  two  weeks  to  five  months  at 
the  latest  in  all  the  operations  of  this  kind  that  have  so 
far  been  reported. 

Among  the  modifications  of  Motais' operation  (for  it  also  has  already 
been  modified)  I  may  name  that  of  Cannas,  who  stitches  the  tendon  of 
the  levator  to  the  belly  of  the  superior  rectus  muscle.  A  vertical  inci 
sion  extending  over  the  entire  lid  is  made  for  the  purpose  of  finding 
the  tendon  of  the  levator  palpebrarum  superior ;  this  is  dissected  away 
from  the  tarsus  for  a  distance  of  5  to  6  mm. ;  and  at  the  same  distance 
from  the  tarsus  a  catgut  suture  is  passed  through  the  tendon  and  the 
latter  divided  above  the  suture.  The  superior  rectus  is  then  exposed, 
and  the  peripheral  ends  of  the  levator  approximated  to  the  rectus  by 
means  of  the  catgut  suture. 

When  the  function  of  the  levator  is  impaired  without 
being  entirely  deficient,  a  very  different  method  may  be 
pursued.  This  is  the  case  in  many  congenital  or  acquired 
forms  of  moderately  severe  ptosis  with  considerable  cos- 
metic or  functional  disturbance.  In  such  cases  the  muscle 
or  the  tendon  may  be  shortened  or  the  insertion  may  be 
placed  more  deeply ;  in  other  words,  a  kind  of  advance- 
ment may  be  made,  a  procedure  which  is  quite  out  of  the 
question  when  the  muscle  is  entirely  paralyzed  or  defi- 
cient. Among  the  many  procedures  of  this  kind  the  fol- 
lowing may  be  mentioned  : 

7.  Ptosis  Operation  of  Eversbusch. — The  patient 
having  been  anesthetized,  Snellen's  lid  clamp  (Fig.  124) 
is  applied,  pushed  well  up  behind  the  affected  lid.  Before 
the  clamp  is  closed  the  skin  of  the  lid  should  be  drawn 


OPERATIONS  ON  LIDS  AND   CONJUNCTIVAL  SAC,    303 

down  as  much  as  possible  toward  the  palpebral  margin, 
so  that  after  the  screw  has  been  closed  the  prolongation 
of  the  lid  (transitional  fold  and  skin  beneath  the  eyebrow) 
may  be  caught  in  the  instrument.  Midway  between  the 
edge  of  the  lid  and  the  eyebrow  an  incision  is  now  made 
between  the  skin  and  the  orbicularis  layer,  parallel  to  the 
palpebral  margin  ;  the  skin  with  the  subjacent  muscle  is 
then  dissected  away  upward  and  downward  to  a  distance 
of  4  mm.  both  ways,  and  loosened  from  its  foundation,  so 
that  the  upper  transitional  fold  and  the  insertion  of  the 
levator  at  the  tarsal  plate  of  the  lid  can  be  exposed.  The 
levator  tendon  is  then  drawn  down  by  means  of  three 
vertical  double  sutures,  or  folded,  so  to  -peak.  At  the 
center  of  the  tendon,  above  its  insertion  in  the  tarsus,  a 
suture  witli  two  needles  is  inserted  horizontally  across,  so 
that  the  points  of  entrance  and  exit  through  the  tendon 
are  about  2.5  mm.  apart.  Two  needles  are  then  carried 
outward  on  the  tarsus — i.  e.,  between  the  tarsus  and  the 
orbicularis  ;  brought  out  at  the  free  border  of  the  lids, 
also  at  a  distance  of  about  2.5  mm.,  and  tied  over  a  glass 
bead  in  order  to  prevent  them  from  cutting  into  the  tis- 
sues. The  two  other  sutures  are  introduced  in  the  same 
way  to  the  right  and  to  the  left  of  the  central  suture,  in 
the  temporal  and  nasal  portions  of  the  levator  tendon,  and 
carried  downward,  so  that  the  tendon  is  drawn  forward  and 
outward  by  three  separate  loops.  The  skin  wound  is  then 
closed,  and  a  double  bandage  must  be  worn  for  several  days. 

Later,  Eversbusch  modified  the  operation  in  cases  of 
paretic  or  paralytic  ptosis  by  the  addition  of  partial  re- 
section of  the  adjoining  orbicularis  muscle,  after  drawing 
the  levator  tendon  to  the  upper  edge  of  the  tarsus.  The 
advancing  sutures  were  carried  through  the  skin,  frontal 
muscle,  levator  tendon,  superior  tarso-orbital  fascia,  orbic- 
ularis muscle,  and  the  skin  of  the  lid,  and  tied  outside  on 
the  skin,  over  glass  beads. 

8.  Snellen  shortens  the  levator  muscles  by  excising  a 
horizontal  oval  piece.  He  makes  a  skin  incision  over  the 
entire  breadth  of  the  lid,  making  it  coincide  as  nearly  as 


304  OPERATIONS  ON  THE  EYE. 

possible  with  a  fold  in  the  skin.  The  orbicularis  is  divided 
and  drawn  apart.  A  little  above  the  upper  edge  of  the 
tarsus  the  orbitotarsal  fascia  is  incised.  The  globe  mean- 
while is  protected  by  a  Jäger  plate;  the  eyelid  is  drawn 
well  downward,  and  from  2  to  5  curved  needles  with  sutures 
are  introduced  in  a  fan-shaped  arrangement  through  the 
levator  muscle  and  tendon  in  the  direction  from  muscle  to 
tarsus ;  and  on  the  needles  an  oval  piece,  with  the  long 
axis  running  transversely,  is  excised.  The  needles  are 
then  drawn  through  and  the  sutures  tied.  Later,  Snellen 
merely  introduced  the  sutures  and  tied  them  without  excis- 
ing the  muscle  and  tendon.  In  mild  cases  he  thinks  the 
suture  alone,  without  any  skin  wound,  is  sufficient.  Both 
ends  of  the  doubly  armed  suture  are  passed  through  the 
thickness  of  the  lid,  beginning  at  the  fornix  of  the  con- 
junctiva, one  end  as  far  back  as  possible  through  the 
conjunctiva  and  the  muscle,  and  the  other  end  through  the 
broad  edge  of  the  tarsus;  while  the  points  of  exit  on  the 
outside  of  the  lid  are  brought  close  together  and  the  sutures 
tied  over  beads. 

9.  Two  other  methods  of  shortening  the  levator  or 
advancing  it  were  suggested  by  H.  Wolff. 

By  making  a  careful  anatomic  investigation  of  the  insertion  of  the 
levator  in  the  tarsus  he  discovered  that  the  upper  part  of  the  tendon  is 
inserted  in  the  anterior  surface  of  the  tarsus,  about  midway  between 
the  upper  and  lower  margins,  along  a  line  of  insertion  running  horizon- 
tally and  approximately  parallel  to  the  free  border  of  the  lid.  This 
line  of  insertion  is  about  5  mm.  distant  from  the  free  border  of  the  lids 
at  every  point.  The  tendon  is  as  strong  and  firm  as  that  of  one  of  the 
recti.  The  surface  of  the  tendon  gives  rise  to  numerous  connective- 
tissue  plates  running  outward  and  forward  between  the  bundles  of  orbic- 
ularis muscle  (Schwalbe)  and  ultimately  inserted  into  the  skin.  The 
upper  border  of  the  tarsus  also  gives  insertion  to  the  superior  palpebral 
muscle  of  Heinrich  Müller,  which  in  an  anatomic  sense  is  also  to  be 
regarded  as  one  of  the  tendons  of  the  levator. 

This  insertion  line  on  the  tarsus,  which  Wolff  discovered,  makes  it 
possible  to  use  a  shortening  operation  on  the  tendon  like  that  performed 
by  Schweigger  on  the  recti  muscles — i.  e.,  leaving  the  normal  insertion 
and  advancing  the  tendon  by  means  of  securely  holding  sutures. — 
Elschnig,  however,  whose  procedure  will  be  described  later,  denies  the 
existence  of  this  insertion  as  described  by  Wolff,  on  the  strength  of  a 
great  many  anatomic  preparations. 


OPERATIONS  ON  LIDS  AND   CONJUNCTIVAL   SAC.    305 

In  one  method  Wolff  exposes  the  levator  tendon  dis- 
covered by  him  in  front  of  the  upper  portion  of  the  tarsus, 
to  a  breadth  (horizontally)  of  about  1  cm.,  by  mean-  of 
the  two  strabismus  hooks,  and  shortens  the  tendon  by  re- 
section in  the  same  way  as  in  Schweigger's  operation  for 
strabismus  (p.  258).  In  his  second  method  Wolff,  after 
everting  the  lid  twice,  goes  in  after  the  muscle  from  the 
conjunctival  side  by  dividing  the  conjunctiva  horizontally. 


Fig.  129.— Lapersonne's  ptosis  operation. 

The  intermediate  isolated  portion  of  the  muscle  is  also 
seized  with  two  strabismus  hooks  of  a  measuring  spatula 
and  secured  in  the  same  way  with  catgut  sutures,  after 
which  it  is  resected  as  in  the  above-mentioned  procedures. 
Later,  Wolff  added  a  skin  incision  for  the  purpose  of 
draining  the  wound  and  preventing  swelling. 

10.  Recently,  I^apersonne  advised  the  following  oper- 
ation  (see   Fig.   129) :      Incision   through   the    skin    and 

20 


306  OPERATIONS  ON  THE  EYE. 

orbicularis,  4  to  5  mm.  above  the  edge  of  the  lid,  exposing 
the  tendon  of  the  levator ;  two  vertical  incisions  as  far 
as  the  conjunctiva,  to  permit  the  introduction  of  a  strabis- 
mus hook  ;  introduction  of  sutures  armed  with  two  needles, 
one  in  the  nasal  and  the  other  in  the  temporal  portion  of 
the  tendon.  After  the  tendon  has  thus  been  secured  it 
is  divided  below  the  suture  and,  if  necessary,  a  piece 
may  be  excised.  The  sutures  are  then  passed  through  the 
tarsus,  at  a  distance  of  2  to  3  mm.  toward  the  edge  of 
the  lid,  and  each  suture  is  tied.  In  most  cases  it  is  better 
to  excise  a  section  from  the  skin  of  the  lid  as  well  as  from 
the  orbicularis.     The  skin  wound  is  then  closed. 

11.  Elschnig,  in  his  operation  for  advancement  of  the 
levator  to  correct  cases  of  incomplete  ptosis,  adopts  yet 
another  method  :  Skin  incision  parallel  to  the  free  edge 
of  the  lid  and  3  to  4  mm.  above  it  along  the  entire  extent 
of  the  eyelid.  The  upper  part  of  the  skin  of  the  lid  is 
then  dissected  away  in  such  a  way  that  the  greater  part  of 
the  orbicularis  remains  bound  to  it,  and  is  then  drawn 
upward,  whereby  the  lower  half  of  the  tarso-orbital  fascia 
is  exposed.  The  lid  having  been  well  drawn  down  to 
render  the  fascia  tense,  the  latter  is  then  incised  about  10 
mm.  above  the  palpable  convex  border  of  the  tarsus  along 
its  entire  extent,  in  a  line  parallel  to  the  edge  of  the  lid. 
Immediately  underneath  the  tarso-orbital  fascia  is  the  thin 
layer  of  the  levator,  which  is  exposed  by  gently  pushing 
back  the  fascia.  The  levator  is  now  seized  at  a  distance 
of  from  5  to  10  mm.  above  the  convex  border  of  the 
tarsus  with  a  loop  running  perpendicularly  to  the  axis  of 
the  fibers,  and  divided  immediately  below  for  a  distance  of 
from  3  to  4  mm.,  after  which  the  division  of  the  muscular 
layer  along  the  entire  extent  of  the  lid  is  completed 
with  scissors  in  a  line  parallel  to  the  edge  of  the  palpebral 
margin. 

The  peripheral  portion  of  the  divided  tarso-orbital 
fascia  is  then  undermined  with  scissors  as  far  as  the 
middle  of  the  tarsus,  or,  rather,  to  the  lower  edge  of  the 
skin  wound,  so  as  to  form  a  pocket,  and  entirely  isolated 


OPERATIONS  ON  LIDS  AND   CONJUNCTIVAL  SAC    307 

from  the  surface  of  the  tarsus,  so  that  the  cartilage  can  be 
exposed  by  drawing  up  the  bridge  of  fascia,  which  is  only 
fixed  to  the  two  sides  of  the  lid.  The  advancement  of 
the  muscular  layer  is  effected  by  seizing  the  free  proximal 
border  with  three  doubly  armed  sutures,  passing  each 
suture  through  the  bridge  of  fascia  in  a  direction  per- 
pendicular to  the  edge  of  the  lid,  then  introducing  each 
needle  vertically  through  the  tarsus  and  conjunctiva  along 
the  lower  edge  of  the  skin  wound  and  bringing  it  out  in 
the  same  way  2  mm.  above  the  free  edge  of  the  lid — i.  e., 
about  2  mm.  from  the  line  of  the  lashes,  through  the  con- 
junctiva, tarsus,  and  skin,  or,  in  other  words,  through  the 
entire  thickness  of  the  lid  from  behind  forward.  Great 
care  must  be  exercised  to  see  that  all  the  sutures  are  car- 
ried vertically  through  the  lid.  Each  pair  of  sutures  is 
passed  through  the  lid,  in  the  manner  described,  at  a  dis- 
tance of  about  3  mm.  from  the  next,  so  as  to  draw  the 
muscular  layer  down  to  the  middle  of  the  tarsus.  The 
tarso-orbital  fascia  is  then  united  again  with  two  catgut 
sutures  (it  is  best  to  introduce  these  sutures  at  the  very 
beginning,  when  the  fascia  is  divided),  and  finally,  after 
the  skin  incision  has  been  closed,  the  muscle  sutures  are 
also  tied  over  sterile  pledgets  of  cotton. 

Instead  of  excising  a  piece  from  the  tendon,  some 
operators  excise  from  the  tarsus.  The  first  of  these  was 
Boucheron,  who  excised  a  strip  of  tarsus  along  with  the 
orbicularis,  cutting  in  through  the  conjunctiva  in  order  to 
avoid  any  scar  in  the  skin.  Similar  procedures  are  recom- 
mended by  Nicati,  Heisrath,  and  Gillet  de  Grandmont. 
Later,  Gruening  again  discovered  this  method  of  excising 
the  tarsus  and  practised  it  to  some  extent.  Marple  had 
very  good  results  with  it  in  cases  of  traumatic  ptosis. 

12.  Gillet  de  Grandmont,  after  applying  a  Snellen's 
clamp,  incises  the  skin  along  a  line  parallel  to  the  edge  of 
the  lid,  3  to  4  mm.  away  from  it,  making  an  incision  about 
2  to  5  cm.  in  length.  The  tarsus  is  thus  completely  ex- 
posed, and  from  it  he  excises  a  crescent-shaped  piece,  the 
lower  border  of  which  is  2  cm.  long  and  runs  parallel  to 


308  OPERATIONS  ON  THE  EYE. 

the  edge  of  the  lids,  at  a  distance  of  2  to  4  mm.  from  the 
same,  while  the  upper  curved  incision  is  placed  as  far 
away  from  the  lower  incision  as  is  necessary  for  the  proper 
elevation  of  the  lid.  The  conjunctiva  is  excised  along 
with  it.  The  edges  of  the  tarsus  are  then  united  with 
three  fine  catgut  sutures.  It  is  not  necessary  to  suture 
the  skin. 

Finally,  it  may  be  mentioned  that  there  are  cases  of 
traumatic  ptosis  in  which  the  tendon  of  the  levator  pal- 
pebrarum superior  is  torn  and  turned  away  from  the 
tarsus  and  must  be  picked  up  and  reunited  to  the  tarsus 
with  sutures.  Green,  in  1871,  adopted  this  procedure 
with  good  success  in  a  case  in  which  complete  ptosis  had 
been  produced  by  a  blow  from  a  cow's  horn,  the  levator 
tendon  having  been  completely  torn  away.  In  making  a 
choice  between  the  various  methods  in  an  operation  for 
ptosis,  it  must  always  be  borne  in  mind  that  closure  of  the 
lid  must  not  be  rendered  impossible. 

It  is  needless  to  say,  also,  that  the  operation  selected 
must  be  adapted  to  the  particular  form  of  ptosis  in  each 
case.  When  the  levator  is  completely  paralyzed  or  absent, 
the  only  operation  to  be  considered  is  one  in  which  the 
frontal  or  superior  rectus  muscle  is  utilized.  On  the  other 
hand,  if  the  levator  is  only  weakened,  advancement  or 
shortening  of  the  tendon  or  of  the  tarsus  is  a  perfectly 
proper  operation.  If  the  lid  is  lengthened  and  the  tissues 
are  thick,  excision  is  especially  indicated  for  the  purpose 
of  reducing  the  size  and  weight. 

II.  OPERATIONS  FOR  ENTROPION. 

Spastic  entropion  is  usually  temporary  and  confined 
to  the  lower  lid  in  old  persons,  especially  after  an  oc- 
clusive bandage  has  been  applied  (after  an  operation  or 
for  keratitis).  Aside  from  flaccidity  of  the  skin  and  de- 
pression of  the  globe,  the  chief  predisposing  factor  is 
blepharophimosis  (Plate  4,  Fig.  17),  and  the  condition  is 
best  corrected  by  means  of  a  Gaillard  suture. 


OPERATIONS  FOR  ENTROPION.  309 

In  some  cases  the  condition,  which  is  especially  apt  to 
be  unpleasant  in  patients  who  have  been  operated  upon 
for  cataract,  can  be  controlled  by  applying  strips  of  ad- 
hesive plaster  in  such  a  way  as  to  draw  the  skin  of  the 
lower  lid  away  from  the  palpebral  margin  and  toward  the 
cheek  : 

1.  By  means  of  Gaillard's  suture  the  skin  of  the  lid 
is  temporarily  shortened,  a  fold  being  caught  in  one  or  two 
sutures.  With  the  thumb  and  index  finger  of  the  left 
hand  a  horizontal  fold  of  the  skin  of  the  lower  lid  is 
picked  up  and  its  base  transfixed  with  the  two  needles  of 
a  doubly  armed  suture,  entering  about  3  mm.  from  the 
palpebral  margin  and  emerging  about  15  mm.  below  it. 
The  second  needle  is  introduced  in  the  same  way  as  the 
first,  at  a  distance  of  3  mm.  from  it,  and  carried  down- 
ward. The  sutures  are  then  tied  over  a  small  piece  of 
rubber  tube  or  cotton  pledget  (Plate  13,  Fig.  2).  If  de- 
sired, a  second  suture  can  be  introduced  in  the  same  way. 
The  sutures  are  removed  after  two  or  three  days.  The 
fold  smoothes  out  again  later,  but  in  the  meantime  the 
irritation,  which  was  responsible  for  the  blepharospasm,  as 
a  rule,  disappears. 

If  the  entropion  recurs  the  skin  may  be  permanently 
shortened  by  excising  a  piece,  the  shape  of  a  myrtle  leaf, 
from  the  lower  lid,  quite  near  the  edge,  along  with  the 
subjacent  orbicularis  muscle,  and  closing  the  wound  with 
a  few  sutures.  A  still  better  operation  in  these  cases  is 
that  devised  by  Hotz  (see  p.  311). 

The  condition  known  as  partial  trichiasis,  in  wThich  a 
limited  number  of  cilia  are  turned  inward  and  rub  against 
the  globe,  is  usually  caused  by  small  scars  remaining  after 
hordeolum,  diphtheria,  burns,  or  operations  on  the  inner 
side  of  the  lid. 

2.  The  best  treatment  consists  in  destroying  the  roots 
of  the  cilia  by  electrolysis,  as  extraction  of  the  mis- 
placed cilia  brings  but  temporary  relief  from  the  condi- 
tion, which  is  often  followed  by  corneal  disease,  or,  at 
least,  corneal  irritation,  for  the  cilia  grow  again  in  a  short 


310 


OPERATIONS  ON  THE  EYE. 


time.  Electrolysis  is  effected  by  means  of  a  small  sharp 
needle  fixed  in  a  holder,  through  which  an  electric  current 
of  about  2  milliamperes  from  a  constant  battery  of  the 
necessary  number  of  elements  is  passed  into  the  needle. 
The  latter  forms  the  negative  pole ;  while  the  positive 
pole,  an  ordinary  flat  electrode,  after  having  been  well 
moistened,  is  applied  to  the  patient's  temple  or  placed  in 
his  hand.  It  is  well  to  inject  a  little  cocain  solution  sub- 
cutaneously  at  the  affected  area  of  the  palpebral  margin, 


^vuuUuJj^ft, 


Fig.  130.— Trichiasis  operation  by  Spencer  Watson. 

because,  after  the  needle  has  been  introduced  into  the 
follicle  close  to  the  eyelash,  the  closure  of  the  electric 
current  causes  rather  severe  pain.  After  from  five  to  ten 
seconds,  during  which  small  bubbles  of  hydrogen  emerge 
from  the  tissue  around  the  needle,  the  follicle  will  be 
destroyed,  as  appears  from  the  fact  that  the  eyelash  either 
follows  the  needle  as  it  is  withdrawn  or  is  removed  by  a 
very  slight  pull  with  the  forceps;  if  it  has  not  been 
destroyed  the  procedure  must  be  repeated. 


OPERATIONS  FOR  ENTROPION.  311 

When  the  trichiasis  extends  over  a  larger  area  and  in- 
cludes, say,  the  outer  or  inner  half  of  the  palpebral  mar- 
gin, Spencer  Watson's  operation  is  indicated. 

8.  Spencer  Watson's  operation  consists  in  trans- 
plantation of  the  misplaced  cilia  by  displacing  a  flap  (Fig. 
130).  An  assistant  having  introduced  a  horn  plate,  the 
entire  portion  of  the  skin  affected  with  entropion  is  loos- 
ened. With  the  thumb  of  the  left  hand  the  skin  of  the 
upper  lid  is  drawn  slightly  upward,  and  the  eyelid  is  then 
divided  into  a  main  anterior  layer  bearing  the  cilia,  and  a 
posterior  layer  composed  of  tarsus  and  conjunctiva,  mak- 
ing the  division  as  deep  as  may  be  required  for  the  lower 
flap,  a.  This  part  of  the  operation  is  best  performed  with 
an  iridectomy  knife  or  a  Beer's  cataract  knife  (Fig.  119). 
Above  this  the  main  flap,  b,  is  formed,  and  then  the  two 
are  made  to  change  places,  so  that  a  lies  above,  and  the 
cilia  are  drawn  away  from  the  globe. 

Complete  (general)  trichiasis,  or  extensive  inward  dis- 
placement of  the  cilia  along  the  entire  palpebral  margin, 
requires  an  operation  by  which  the  position  of  the  entire 
ciliary  soil  is  altered.  One  of  the  best  of  the  numerous 
operations  that  have  been  recommended  for  this  purpose  is 
known  as 

4.  Hots's  Operation  for  Entropion. — The  main 
objects  of  this  operation  are  to  draw  away  the  skin  from 
the  cilia  with  the  edge  of  the  lid  and  fasten  the  latter  to  the 
tarsus  and  tarso-orbital  fascia.  It  can  be  performed  both 
on  the  upper  and  on  the  lower  lid.  In  the  former  case  the 
lid  is  drawn  down  over  a  horn  plate,  which  may  have  to  be 
dispensed  with,  and  a  horizontal  incision  is  carried  right 
across  the  lid.  This  incision  should  follow  the  curved 
line  of  the  upper  edge  of  the  tarsus,  the  breadth  of  which 
is  subject  to  individual  variations.  When  the  eye  is  closed 
the  edge  of  the  tarsus  is  readily  recognized  by  a  delicate 
wrinkle  in  the  skin,  beginning  about  2  mm.  above  the 
inner  canthus  and  rising  gently  to  the  middle  of  the  lid, 
and  from  that  point  falling  gradually  to  the  external  can- 
thus.     As  it  is  difficult,  owing  to  the  extreme  looseness  of 


312 


OPERATIONS   ON  THE  EYE. 


the  skin  of  the  upper  lid,  to  follow  this  curve  with  a 
knife,  it  is  better  to  draw  the  lid  well  down  in  the  manner 
described,  as  it  has  the  effect  of  converting  the  curved  into 
a  straight  line,  which  can  easily  be  followed  with  the  knife 
on  the  tense  lid.  This  incision  is  carried  from  a  point  2 
mm.  above  the  inner  angle  of  the  lid  to  a  point  2  mm. 
above  the  outer  angle.  As  soon  as  the  skin  has  been 
divided  the  upper  edge  of  the  wound  retracts  (Fig.  131). 
The  orbicularis  is  now  cautiously  divided  exactly  along 


\^ 


Fig.  131.— Hotz's  entropion  operation. 


the  lower  edge  of  the  wound  until  the  yellowish-red  color 
of  the  tarsus  becomes  apparent.  The  upper  edge  of  the 
tarsus  is  readily  recognized  by  the  marked  contrast  between 
the  yellowish  tendinous  color  and  the  grayish-red  color 
which  shines  through  the  tarso-orbital  fascia  at  this  point. 
The  latter  must  not  be  wounded  during  this  operation. 

After  the  palpebral  portion  of  the  orbicularis  has  been 
separated  in  this  way  from  the  orbital  portion  throughout 
the  entire  width  of  the  lid,  and  has  been  loosened  from 
the  tarsus  along  with  the  skin,  the  operator  lets  go  the  lid, 


OPERATIONS  FOR  ENTROPION.  313 

whereupon  the  wound  at  once  ceases  to  gape  and  the  in- 
cision exactly  coincides  with  the  curve,  with  the  above- 
mentioned  wrinkle  in  the  skin.  The  assistant  now  turns 
the  skin  slightly  backward  at  the  center  of  the  lower  edge 
of  the  wound,  so  as  to  bring  the  orbicularis  into  view. 
The  operator  then  seizes  the  muscle  fibers  nearest  the  edge 
of  the  skin  with  a  delicate  pair  of  forceps,  and  dissects 
away  a  strip  about  3  mm.  broad  from  the  center  of  the 
edge  of  the  skin  to  each  angle.  The  edge  of  the  skin  and 
the  upper  portion  of  the  tarsus  must  be  absolutely  free 
from  muscle  fibers. 

In  applying  the  sutures  the  needle  is  introduced  first 
through  the  lower  lip  of  the  wound,  2  mm.  from  the  edge, 
while  the  assistant  pushes  the  upper  lip  of  the  wound 
upward  with  his  index  finger  and  the  operator  draws  the 
lower  one  down.  The  needle  is  introduced  2  mm.  above  the 
upper  edge  of  the  tarsus,  through  the  aponeurosis,  passes 
upward  along  the  tarsus,  and  made  to  emerge  about  2  cm. 
above  it  through  the  tarso-orbital  fascia.  Finally,  it  is 
introduced  through  the  corresponding  point  on  the  upper 
edge  of  the  skin,  care  being  taken  that  the  sutures  contain 
nothing  but  skin,  and  avoids  the  orbicularis  fibers.  Three 
or  four  such  sutures  are  required,  and  care  must  be  exer- 
cised to  see  that  the  skin  edges  are  accurately  approxi- 
mated. 

The  eye  is  dressed  with  iodoform  gauze  and  cotton,  and 
the  bandage  may  be  dispensed  with  after  from  two  to  three 
days,  when  the  sutures  may  also  be  removed. 

The  same  procedure  is  recommended  for  the  lower  lid. 
When  the  skin  is  long  and  loose,  especially  in  old  people, 
the  operator  must  be  careful  not  to  make  the  skin  incision 
too  far  from  the  edge  of  the  lid,  so  as  to  make  sure  that 
the  skin  is  sufficiently  put  on  the  stretch  on  the  tarsus. 
At  the  same  time  it  may  be  advisable  to  excise  a  narrow 
portion  of  skin. 

Should  this  operation  prove  not  quite  adequate  in  very 
marked  cases,  other  auxiliary  measures  may  be  resorted 
to,  as,  for  example,  the  secondary  excision  of  a  narrow 


314  OPERATIONS  ON  THE  EYE. 

horizontal  strip  of  skin  near  the  edge  of  the  lid.  Or, 
when  the  inward  inclination  of  the  cilia  is  extreme,  the 
condition  may  be  corrected  by  splitting  the  free  edge  of 
the  lid  along  its  entire  extent  and  separating  the  cilia-bear- 
ing portion  from  the  tarsus,  and  then  filling  the  cleft  with 
a  piece  of  skin  from  2  to  3  mm.  wide,  taken  from  some 
hairless  portion  of  the  head  where  the  skin  is  thin,  prefer- 
ably behind  the  ear,  with  Wilder's  double  knife  (Fig.  123). 
I  have  had  occasion  to  convince  myself  that  this  method 
of  transplantation  is  very  generally  successful  and  pro- 
duces a  widening  of  the  palpebral  edge,  as  the  transplanted 
strip  of  skin  fits  in  between  the  cilia  and  the  globe. 

It  is  possible  to  combine  with  Hotz's  operation  excision 
of  a  narrow  piece  of  the  tarsus  running  parallel  to  the 
edge  of  the  lid,  in  case  it  seems  desirable  to  straighten  the 
cartilage.  Wilder's  knife  is  convenient  for  this  excision 
also. 

Hotz's  operation  had  a  predecessor  in  the  form  of  a  sim- 
ilar procedure  devised  by  Anagnostakis  (1857),  which, 
however,  did  not  attract  much  attention.  Anagnostakis 
placed  the  incision  (in  the  upper  lid)  3  mm.  above  and 
running  parallel  with  the  edge  of  the  lid  (that  is  to  say, 
much  nearer  than  Hotz's  incision),  removed  the  muscle 
fibers  covering  the  upper  third  of  the  tarsus  with  forceps 
and  scissors,  and  then  secured  the  lower  lip  of  the  wound 
to  the  upper  edge  of  the  tarsus  by  means  of  sutures,  which 
were  allowed  to  slough  out.  This  method  of  allowing  the 
sutures  to  come  away  by  suppuration  is  less  commendable 
than  the  more  accurate  suturing  advised  by  Hotz,  followed 
by  removal  of  the  sutures  after  two  or  three  days,  as  dis- 
figuring vertical  scars  are  produced  by  the  process  of  sup- 
puration. 

5.  Entropion  Operation  with  Advancement  of 
the  levator  Tendon. — After  Pagenstecher  began  to 
use  Hotz's  operation  he  soon  expanded  it  into  his  own 
entropion  operation  with  advancement  of  the  levator 
tendon. 

In  this  operation    the    surgeon  stands  at  the  patient's 


OPERATIONS  FOR  ENTROPION.  315 

head  and  finds  the  upper  edge  of  the  tarsus  with  the 
index  finger  of  his  left  hand,  which  is  an  easy  matter  in 
most  cases  of  entropion,  because  the  tarsus  is  always  more 
or  less  thickened.  A  short  skin  incision  is  made  about 
1.5  mm.  below  the  upper  edge  of  the  tarsus  as  a  land- 
mark. The  lid  clamp  is  then  introduced,  taking  care  to 
clamp  the  lid  straight,  and  a  horizontal  incision  is  made 
in  the  skin  parallel  to  the  edge  of  the  palpebral  margin  at 
the  point  previously  marked.  This  incision  penetrates  as 
far  as  the  tarsus  at  the  center,  but  on  the  two  sides  divides 
only  the  skin  and  extends  exactly  as  far  as  the  arms  of 
the  clamp.  While  an  assistant  depresses  the  lower  lip 
of  the  incision  downward  at  the  center  of  the  lid  with  a 
small  pair  of  forceps,  which  he  keeps  closed,  the  operator, 
using  the  tip  of  the  left  index  finger,  pushes  the  upper  lip 
of  the  wound  upward  at  a  corresponding  point,  so  that 
the  yellowish,  tense  tarsal  tissue  is  brought  into  view. 
Next  the  upper  half  of  the  tarsus,  and  particularly  the 
tarso-orbital  fascia,  must  be  exposed.  The  assistant 
pushes  the  bundles  of  orbicularis  fibers  downward  while 
the  operator  pushes  them  upward,  and  the  latter  dissects 
away  all  the  bundles  lying  above  the  incision — L  e.,  the 
outermost  curved  fibers  of  the  palpebral  portion  and  the 
orbital  portion  of  the  orbicularis  muscle — pushes  them  up 
with  the  tip  of  the  index  finger,  and  thus  gradually  cleanses 
the  upper  tarsus  throughout  its  entire  extent,  and  exposes 
the  tarso-orbital  fascia,  the  white  color  of  which  contrasts 
sharply  with  the  yellowish  tint  of  the  tarsus,  for  a  dis- 
tance of  3  to  4  mm.  above  the  center  of  the  upper  edge 
of  the  tarsus. 

Next  comes  the  most  difficult  part  of  the  operation, 
namely,  the  introduction  of  the  sutures.  First  a  moder- 
ately curved  needle  with  a  medium-sized  silk  suture  is 
carried  through  the  skin  and  muscular  tissue  about  1 
mm.  above  the  edge  of  the  lid  and  brought  out  on  the 
inner  surface  of  the  lower  edge  of  the  wound,  which  has 
been  picked  up  with  the  forceps.  While  the  assistant 
draws  the  upper  lip  of  the  wound  as  far  up  as  possible, 


316  OPERATIONS  ON  THE  EYE. 

the  operator,  with  a  delicate  rat-tooth  forceps,  takes  firm 
hold  of  the  tarso-orbital  fascia  about  2  to  3  mm.  above  the 
upper  edge  of  the  tarsus,  and  at  the  same  time  raises  a  fold 
of  the  tendon  of  the  levator  palpebrarum,  which  lies 
immediately  underneath.  The  needle  is  then  passed 
through  the  upper  edge  of  the  tarsus  itself  and  the  entire 
thickness  of  the  fold  of  the  levator  tendon  as  it  is  vigor- 
ously drawn  up,  after  which  the  needle  is  brought  out 
through  the  upper  edge  of  the  skin  wound.  Two  other 
sutures  are  then  introduced  in  the  same  way,  one  on  each 
side  of  the  first,  and,  first,  the  central  suture,  and  imme- 
diately afterward,  the  two  lateral  ones  are  tied  as  tightly 
as  possible  and  the  lid  forceps  removed.  Double  band- 
age ;  rest  in  bed ;  first  change  of  dressing  on  the  third 
day.  On  the  fifth  or  sixth  day  the  sutures  are  removed 
and  no  more  dressing  is  applied. 

This  method,  therefore,  differs  from  that  devised  by 
Hotz  in  that  no  muscle  bundles  are  removed,  and  the 
same  cicatricial  union  is  achieved  between  the  orbicularis 
fibers  on  the  one  hand,  and  the  upper  edge  of  the  tarsus 
with  the  fascia  and  the  levator  tendon  on  the  other  hand, 
the  tendon  being  advanced  and  the  direction  of  its  action 
changed. 

In  other  operative  methods  entropion  is  combated  by 
altering  the  shape  of  the  tarsus — tarsoplastic  operation. 
This  is  effected  by  dividing  the  cartilage  horizontally,  or 
excising  a  horizontal  wedge-shaped  strip,  thus  causing 
outward  rotation  of  the  lower  edge  of  the  tarsus.  Such 
an  operation  on  the  tarsus,  however,  is  justified  only  in 
those  cases  in  which,  usually  owing  to  trachoma,  there  is 
already  such  extensive  disease  of  the  tarsus  that  the 
Meibomian  glands  have  all  been  destroyed,  as  the  latter 
would  otherwise  be  greatly  injured  by  the  procedure.  The 
operation  is  especially  adapted  to  the  upper  lid. 

6.  Streatfield's  entropion  operation  includes  exci- 
sion of  a  prism-shaped  piece  from  the  cartilage,  and 
should  be  mentioned  first  among  these  methods  (1858). 
To  control  hemorrhage  and  keep  the  parts  in  the  proper 


OPERATIONS  FOR  ENTROPION.  317 

position  he  used  a  Desmarres'  clamp  (Fig.  122),  and  car- 
ried an  incision  2  to  3  mm.  above  the  cilia  along  the  pal- 
pebral margin  oVer  the  entire  width  of  the  eyelid  as  far 
as  the  cartilage,  without  injuring  the  follicles.  He  then 
made  a  second  incision  parallel  to  the  first  and  3  mm. 
higher,  which,  by  tracing  a  slight  curve,  was  made  to  unite 
with  the  first  at  the  temporal  and  nasal  extremities.  The 
two  incisions  are  then  continued  into  the  tarsus  until  they 
meet,  and  in  this  way  a  long  prismatic  or  wedge-shaped 
strip  is  excised,  which  is  then  dissected  out  along  with  the 
superimposed  muscle  and  cutaneous  layer  with  scissors 
and  scalpel.  In  certain  cases  of  simple  entropion  the 
knife  must  be  handled  very  carefully,  so  as  not  to  cut 
through  the  tarsus  and  the  ducts  of  the  Meibomian  glands. 
Although  this  was  laid  down  as  a  necessary  condition  of 
the  operation,  it  is  a  condition  that  is  not  easily  fulfilled. 
Xo  sutures  were  introduced  after  the  operation. 

7.  Snellen's  entropion  operation  with  excision  of 
the  tarsus  was  developed  as  a  modification  of  Streatfield's. 
Snellen  used  his  own  lid  clamp  (Fig.  124),  made  an  incision 
extending  over  the  entire  breadth  of  the  eyelid,  between 
2  and  3  mm.  above  the  cilia,  and  with  the  scissors  excised 
the  underlying  muscle  bundles.  The  wedge-shaped  strip 
of  tarsus  was  then  excised  by  means  of  two  oblique  inci- 
sions extending  almost  to  the  posterior  surface  of  the 
tarsus,  and  the  wound  was  finally  closed  with  three  doubly 
armed  silver  sutures  (sterilized  silk  is  just  as  good).  One 
needle  is  introduced  through  the  upper  portion  of  the 
tarsus,  the  second  3  mm.  horizontally  alongside  of  it,  also 
through  the  tarsus,  after  which  the  needles  are  carried  from 
the  lower  lip  of  the  wound  underneath  the  skin  at  the  palpe- 
bral margin  and  brought  out  immediately  above  the  cilia. 
Here  the  corresponding  sutures  are  securely  tied  over  a 
glass  bead  to  prevent  their  cutting  into  the  tissue.  The 
skin  incision  requires  no  sutures. 

8.  Hots  himself,  for  certain  cases  of  trichiasis  of  the 
upper  lid,  supplemented  his  above-described  operation 
with  a  tarsus  excision.     This  he  did  in  cases  in  which 


318  OPERATIONS  ON  THE  EYE. 

the  free  edge  of  the  lid  is  rotated  inward,  owing  to  con- 
traction of  the  conjunctiva  and  posterior  portion  of  the 
tarsus,  and  lie  in  the  same  plane  as  the  conjunctiva  of  the 
lid,  so  that  the  conjunctiva  appeared  to  reach  to  the  eye- 
lashes. The  inward  rotation  of  the  palpebral  margin  is 
accompanied  by  a  similar  inclination  of  the  cilia  toward 
the  globe,  with  which  they  ultimately  come  in  contact. 
In  these  cases  Hotz  restores  the  proper  position  of  the 
palpebral  margin  by  combining  his  above-described  opera- 
tion with  excision  of  an  oblique  wedge  near  the  edge  of 
the  lid.  The  first,  lower,  incision  is  carried  vertically 
through  the  tarsus  immediately  above  the  follicles  of  the 
cilia  ;  the  second,  above,  running  obliquely  outward.  The 
incisions  meet  in  the  posterior  portion  of  the  tarsus,  about 
3  mm.  above  the  edge,  in  a  line  corresponding  to  the 
posterior  edge  of  the  inverted  palpebral  margin.  After 
removal  of  the  strip  of  tarsus  the  anterior  edge  of  the  lid 
may  return  to  its  normal  position  and  the  cilia  resume 
their  normal  position  perpendicular  to  the  globe.  After 
the  hemorrhage  has  been  controlled,  3  or  4  sutures  are 
carried  through  the  lower  edge  of  the  tarsus  and  ultimately 
through  the  upper  edge  of  the  skin  wound. 

9.  Division  of  the  tarsus  after  Panas  is  the  method 
employed  by  the  latter  chiefly  for  cases  of  severe  and 
obstinate  trichiasis  with  entropion  occurring  in  trachoma- 
tous subjects.  He  prefers  Jäger's  horn  plate  (Fig.  121), 
and  makes  his  incision  horizontally,  3  mm.  above  the  row 
of  cilia  and  extending  over  the  entire  lid  to  the  tarsus. 
The  latter  is  then  completely  exposed,  both  above  and 
below,  by  dissecting  away  the  orbicularis  muscle  with  knife 
and  forceps,  but  the  cartilage  is  not  excised.  Below,  the 
edge  of  the  skin-muscle  wound  is  undermined  only  as  far 
as  the  cilia.  If  the  tarsus  is  not  abnormal  it  is  allowed  to 
remain  intact ;  but  if  it  is  bent  and  thickened  the  entire 
structure,  including  the  conjunctiva  (that  is,  as  far  as  the 
horn  plate),  must  be  divided  in  a  direction  perpendicular 
to  its  surface  (Fig.  132).  The  needles  are  so  introduced 
as  first  to  seize  the  aponeurosis  and  the  upper  edge  of  the 


OPERATIONS  FOR  ENTROPION. 


319 


tarsus ;  they  are  then  passed  underneath  the  lower  lip  of 
the  wound  and  brought  out  immediately  behind  the  eilia. 
Although  the  upper  lip  of  the  skin  wound  is  not  included 
in  the  suture,  the  wound  closes,  nevertheless,  and  after 
the  sutures  have  been  tied  they  are  not  cut  off,  but  are 
drawn  together  in  a  bundle  and  fastened  to  the  forehead, 
above  the  eyebrows.  The  sutures  are  removed  after  three 
to  four  days,  and  an  occlusive  bandage  is  worn  a  few  days 
longer. 

10.  The  entropion  operation  devised  by  Pfals  is 
related  both  to  that  of  Snellen  and  that  of  Panas,  and  is 


Fig.  132.— Entropion  operation  by  Panas. 

suitable  for  severe  cases.  The  entire  width  of  the  lid  is 
excised  immediately  above  the  lowest  row  of  eyelashes, 
the  edge  of  the  knife  being  directed  slightly  upward  and 
backward.  By  means  of  a  second  incision,  running  3.5 
mm.  above  and  parallel  to  the  first,  a  narrow  flap  of  skin 
is  outlined  and  then  excised.  The  orbicularis  may  be 
excised  in  the  entire  operative  field  ;  the  orbicularis  is  then 
also  excised  in  the  entire  extent  of  the  wound,  and  the 
tarsus  having  thus  been  exposed,  a  wedge-shaped  piece 
about  2  mm.  wide  is  excised  from  the  base,  the  rounded 
apex  corresponding  to  the  point  of  greatest  curvature  of  the 
tarsus.     The  conjunctiva  is  then  also  excised  in  a  horizontal 


320  OPERATIONS  ON  THE  EYE. 

line  a  distance  of  about  6  mm.  along  the  middle  of  the 
flap,  in  order  to  increase  the  mobility  of  the  palpebral 
margin.  The  needle  is  introduced  from  above  through 
the  skin  and  muscle,  passes  through  the  upper  portion  of 
the  tarsus  and  the  lower  portion  of  the  tarsus,  and  is 
brought  out  behind  the  last  rows  of  eyelashes.  Five 
sutures  are  used,  which  are  also  to  be  fastened  to  the  fore- 
head. 

Snellen's  suture  is  used  for  spastic  entropion.  The  two 
needles  of  a  doubly  armed  suture  are  brought  out  through 
the  lid  from  the  transitional  fold,  are  then  reintroduced 
through  the  point  of  exit,  carried  upward  under  the  skin 
of  the  lid,  brought  out  near  the  anterior  palpebral  margin 
and  tied.  Two  or  three  such  sutures  are  required.  This 
procedure  sometimes  fails  of  any  permanent  effects,  and  is 
suitable  only  for  the  lower  lid. 

Ablation  of  the  ciliary  border  after  Flarer  and 
the  improvement  on  the  operation  by  Stellwag,  who  ablated 
the  ciliary  border  and,  after  rotating  it  through  180  degrees, 
replaced  it  in  the  wound  (plastic  operation  on  the  pal- 
pebral margin),  are  hardly  as  good  as  the  above-described 
methods,  and  are  certainly  suitable  only  for  the  lower  lid. 

Displacement  of  the  ciliary  border  after  Jasche- 
Arlt  is  performed  as  follows  :  An  intermarginal  incision 
is  made  and  the  cilia-bearing  edge  of  the  lid  is  undermined 
a  distance  of  4  to  5  mm.  A  crescen tic-shaped  piece  is 
then  excised  from  the  skin  of  the  lid,  which  has  the  eifect 
of  drawing  the  skin  along  with  the  cilia  away  from  the 
palpebral  margin  and  leaving  the  latter  freely  exposed  for 
the  formation  of  granulations  ;  or,  according  to  Waldhauer, 
the  palpebral  margin  is  covered  with  the  excised  piece  of 
skin  (non-peclunculated  transplantation).  This  operation 
is  no  better,  and  often  does  less  good,  than  the  above- 
mentioned  procedures.  It  was  first  proposed  by  Aetius 
and  Paul  of  .ZEgina. 


OPERATION  FOR  BLEPHAROPHIMOSIS.  321 

III.   OPERATION    FOR  BLEPHAROPHIMOSIS. 
Canthoplastic  Operations. 

Entropion  is  not  infrequently  produced  or  favored  by 
blepharophimosis  (Plate  14,  Fig.  1),  which  consists  in  a 
vertical  fold  of  skin  covering  the  external  canthus  and, 
therefore,  apparently  shortening  the  palpebral  fissure ; 
although,  when  the  fold  is  displaced  toward  the  temple, 
the  external  canthus  is  seen  to  be  intact  (while  ankylo- 
blepharon is  caused  by  cohesion  of  the  palpebral  margins). 
Blepharophimosis  is  usually  caused  by  shortening  of  the 
skin  at  the  outer  canthus  in  a  horizontal  direction,  as  in 
chronic  conjunctivitis,  the  skin  becoming  excoriated  from 
contact  with  the  lacrimal  fluid  and  other  secretions,  and 
ultimately  undergoing  contraction.  The  process  is  aggra- 
vated by  periodic  blepharophimosis  and  senility. 

Operation. — The  anomaly  is  corrected  by  dividing  the 
external  canthus  in  a  horizontal  direction.  The  lids  are 
first  well  separated  and  at  the  same  time  drawn  ten.-e 
toward  the  nasal  side,  and  the  external  canthus  is  divided 
horizontally  with  one  snip  of  a  heavy  pair  of  scissors,  after 
which  the  conjunctiva  is  stitched  into  the  wound  (Plate  14, 
Fig.  2),  so  as  to  cover  it,  as  otherwise  the  edges  of  the 
wound  would  rapidly  grow  together  again.  The  needle  is 
inserted  first  into  the  conjunctiva.  The  first  suture  is 
placed  in  a  horizontal  direction,  and  the  two  others  in  a 
direction  outward  and  upward  and  outward  and  downward 
through  the  skin  and  then  tied,  whereby  the  conjunctiva 
is  drawn  into  the  wound.  A  bandage  should  be  worn  for 
several  days. 

Simple  division  of  the  external  canthus  without  intro- 
ducing sutures — provisional  canthoplastic  operation — is 
done  in  cases  of  blepharospasm  leading  to  entropion  and  in 
gonorrheal  conjunctivitis  of  adults  to  diminish  the  press- 
ure exerted  by  the  overstretched  lids  on  the  cornea  ;  also' 
in  enucleation  and  exenteration  of  the  orbit,  as  has  been 
mentioned. 


21 


322 


OPERATIONS  ON  THE  EYE. 


Plate  14. 

Fig.  1. — Blepharophimosis  in  an  old  man :   Vertical  fold  of  skin  in 
front  of  the  outer  canthus. 

Fig.  2. — Canthoplastic  operation  :  Enlarging  the  outer  canthus. 


IV.   TARSORRHAPHY. 

The  outer  or  inner  canthus  may  be  united  with  sutures 
for  exactly  the  opposite  purpose  as  that  for  which  the 
operation  just  referred  to  is  performed,  namely,  to  shorten 
the  palpebral  fissure  in  a  horizontal  direction. 


Fig.  133.— a,  Tarsorrhaphy  after  von  Gräfe;  b,  tarsorrhaphy  after  Fuchs. 

This  operation  is  indicated  in  ectropion  and  in  lagoph- 
thalmos ;  in  the  former  for  the  purpose  of  raising  the  lid 


f 


<M 


:*fl 


OPERATIONS  FOR  ECTROPION.  323 

and  obtaining  better  adaptation  to  the  globe,  and  in  the 
latter  to  provide  a  better  protection  for  the  staring  eye- 
ball by  securing  freer  action  of  the  lid.  For  the  latter 
purpose  the  operation  is  also  performed  in  exophthalmos 
due  to  Basedow's  disease. 

The  operation  is  performed  more  frequently  at  the 
outer  than  at  the  inner  canthus.  The  older  method  (von 
Gräfe's)  consisted  chiefly  in  cutting  away  the  ciliary  bed 
from  the  outer  angle,  freshening  up  the  edges,  and  then 
uniting  them  with  sutures  (Fig.  133,  a).  Later,  Fuchs 
suggested  the  following  improvement :  In  the  lower  lid  a 
small  flap  is  secured  by  splitting  the  lid  along  the  margin, 
dividing  it  into  two  layers,  and  then  adding  a  short 
vertical  incision,  as  shown  in  Fig.  133,  b ;  the  ciliary 
border  of  the  upper  lid  is  then  freshened  up  and  the 
inner  surface  of  the  flap  united  to  it  with  sutures.  The 
two  ends  of  a  doubly  armed  suture  are  passed  through 
the  upper  lid  near  the  free  border,  the  needles  being  intro- 
duced from  behind  forward.  The  loop  of  the  suture  thus 
lies  on  the  conjunctival  side  of  the  lid,  while  the  free  ends 
emerge  from  the  anterior  surface  of  the  wound.  The 
ends  are  then  carried  through  the  lower  flap  and  tied  over 
a  glass  bead.  In  this  way  the  base  of  the  flap  is  pressed 
against  the  raw  surface  of  the  tarsus  of  the  upper  lid, 
and  a  broader  cohesion  surface  is  secured  than  with  von 
Gräfe's  operation. 

Nasal  tarsorrhaphy  after  von  Arlt  consists  in  excis- 
ing a  narrow  <-shaped  strip  of  skin  with  forceps  and 
scissors,  both  from  the  lower  and  the  upper  edge  of  the 
inner  canthus,  and  uniting  the  two  limbs  of  the  wound 
with  vertical  sutures. 

V.  OPERATIONS  FOR  ECTROPION. 

Cases  of  spastic  ectropion  in  which  the  palpebral  margins 
are  forced  outward  by  the  swollen  conjunctiva  and  then 
by  the  contraction  of  the  orbicularis  muscles,  so  that 
eventually  the  lower  or   the   upper  lid  or  both  become 


321  OPERATIONS  ON  THE  EYE. 

Plate  15. 

Fig.  1. — Ectropion  due  to  facial  paralysis  in  the  second  year  of  life : 
The  woman  is  now  fifty-two  years  old,  and  complains  of  profuse  lacri- 
matiou,  the  lower  lacrimal  punctum  was  dilated  with  a  conical  sound 
before  the  picture  was  taken. 

Fig.  2  —  The  same  eye  after  six  months,  after  median  tarsorrhaphy 
with  Szymanowsky's  modification. 

inverted,  may  be  corrected  by  means  of  Snellen's  suture, 
which  represents  the  analogue  of  Gaillard's  suture  for  the 
correction  of  ectropion. 

1.  Snellen's  suture,  like  Gaillard's  suture  on  the 
outside  of  the  lid,  is  designed  to  effect  a  shortening  of  the 
inner  side  of  the  lid  by  means  of  one  or  two  sutures.  The 
two  needles  of  a  doubly  armed  suture  are  introduced  at 
the  level  of  the  deformed  lid,  3  mm.  apart,  between  the 
conjunctiva  and  the  tarsus,  in  a  direction  downward  and 
obliquely  forward,  and  brought  out  through  the  skin  near 
the  orbital  margin  at  the  same  distance  of  3  mm.  from 
one  another,  where  they  are  tied  over  a  small  drainage- 
tube.  Obstinate  (senile,  paralytic)  cases  of  ectropion  will 
not  be  permanently  cured  by  this  method  of  suturing. 

For  paralytic  ectropion  of  the  lower  lid  tarsorrhaphy  is 
a  better  operation. 

2.  For  old  advanced  cases  one  may  recommend  Szym- 
anowsky's Operation,  in  which  the  lower  lid  is  thor- 
oughly elevated  at  the  inner  or  outer  canthus,  while  the 
related  operation  of  Dieffenbach  merely  effects  tension 
and  shortening  of  the  lid  in  a  horizontal  direction. 
Dieffenbach's  operation  consists  in  making  a  skin  incision 
running  toward  the  temple,  in  the  line  of  the  palpebral 
fissure,  and  adding  two  incisions  running  downward  from 
the  extremities  of  the  skin  incision  and  converging  to 
form  an  equilateral  triangle ;  the  sutures  are  introduced 
horizontally  after  the  adjoining  palpebral  margin  has  been 
freshened  up.  In  Szymanowsky's  method  elevation  is 
effected  by  excising  a  flat  triangle,  the  obtuse  angle  of 
which  coincides  with  the  canthus,  while  the  hypothenuse 
runs  in  a  vertical   direction  at  some  distance  from   the 


OPERATIONS  FOR  ECTROPION.  325 

angle  of  the  lid.  In  the  case  shown  in  Plate  15,  in  which 
the  operation  was  so  performed  for  old  ectropion  due  to 
facial  paralysis,  the  vertex  of  the  triangle  was  placed 
slightly  to  the  nasal  side  of  the  lower  lacrimal  punctum. 
From  this  point  the  first  incision  was  carried  past  the 
inner  canthus  and  extended  for  1.5  mm.  in  the  direction 
of  the  inner  extremity  of  the  eyebrow ;  the  second  almost 
vertically  downward  a  distance  of  2.5  cm. ;  and  the  third 
back  to  the  starting-point.  After  this  triangle  of  skin 
had  been  excised  and  the  first  incision  had  been  prolonged 
a  distance  of  0.5  cm.  toward  the  cilia,  the  edges  of  skin 
over  the  denuded  portion  were  united  with  sutures  run- 
ning obliquely  from  without  and  below  inward  and  up- 
ward, so  that  the  beginning  of  the  skin  suture  occupied  a 
point  to  the  nasal  side  of  the  lower  lacrimal  punctum  in 
the  upper  angle  of  the  triangle  referred  to.  The  effect 
of  this  procedure  (as  Fig.  2,  which  was  taken  six  months 
after  recovery,  shows)  may  be  quite  marked. 

Senile  ectropion  of  the  lower  lid,  which  is  quite  com- 
mon, and  some  cases  of  paralytic  ectropion,  may  be  suit- 
ably relieved  by  the  operation  now  to  be  described. 

3.  Kuhnt's  Ectropion  Operation. — Kuhnt  also 
excises  a  triangle,  the  base  of  which,  however,  coincides 
with  the  palpebral  margin,  which  consists  not  of  skin,  but 
of  the  posterior  layer  of  the  lid,  tarsus,  and  conjunctiva. 
The  elongation  of  the  lid,  and  especially  of  the  palpebral 
margin,  present  in  ectropion  is  successfully  corrected  by 
means  of  this  operation.  If  the  cutis  is  also  excised — 
that  is,  a  triangular  piece  is  excised  from  the  entire  lid,  as 
recommended  by  Adams  in  1812,  it  may  happen  that  the 
wound,  owing  to  the  traction  on  the  edges  of  the  skin  flap 
by  the  transversely  divided  muscle  bundles,  fails  to  unite 
and  a  gaping  cleft  remains  in  the  lid  (coloboma). 

An  operation  similar  to  that  of  Kuhnt  was  described 
by  Antyllus  about  300  A.D.  The  operation  can  readily 
be  performed  under  local  anesthesia  (injection  of  cocain 
and  adrenalin  into  the  lid).  Knapp's  forceps  (Fig.  120) 
may  be  used,  but  upside  down,  applying  the  flat  piece  to 


326  OPERATIONS  ON  THE  EYE. 

Plate  1 6. 

Senile  ectropion  in  a  woman  sixty  years  of  age,  with  senile  cataract 
(see  following  Plate). 

Plate  17. 

Fig.  1. — Kuhnt's  ectropion  operation  in  the  same  patient. 

Fig.  2.— Same  eye  three  months  after  the  operation  and  one  month 
after  cataract  operation  without  iridectomy.  Some  secondary  cataract 
remains,  which  was  later  successfully  treated  by  discission. 

the  skin  and  the  curved  part  to  the  conjunctival  side ;  or 
the  lid  may  be  seized  between  two  spatulas  in  such  a  way 
as  to  leave  the  triangle  to  be  excised  between  them  (see 
Czermak  l) ;  or  the  lid  may  simply  be  held  between  the 
thumb  and  index  finger  of  the  left  hand.  The  length  of 
the  piece  of  the  triangle  which  is  to  be  excised  from  the 
center  of  the  lid  is  determined  by  the  degree  of  shortening 
that  is  desired.  A  broad  keratome  is  first  inserted  into 
the  lid,  along  the  free  border,  between  the  cutis  and  tarsus, 
after  which  a  A-shaped  piece  of  tarsus  and  conjunctiva  is 
excised  with  small  straight  scissors,  beginning  at  the  ex- 
tremities of  the  intermarginal  incision  (Plate  17,  Fig.  1. 
Operation  on  the  patient  shown  in  Fig.  16).  The  sutures 
are  then  introduced  as  shown  in  the  figure.  The  first 
suture,  which  is  placed  in  the  skin,  should  be  particularly 
strong  and  take  a  deep  hold  on  the  skin  edges.  As  soon 
as  the  sutures  have  been  tied  the  skin  is,  of  course,  puck- 
ered into  a  fold,  which  stands  vertically  to  the  lid.  This 
fold  may  be  disregarded,  however,  as  it  becomes  obliterated 
in  a  few  weeks  (compare  Plate  17,  Fig.  2),  and  if  it  fails 
to  do  so,  as  in  severe  cases  of  ectropion,  a  small  superficial 
wedge  of  skin  may  be  excised  from  two  to  three  weeks 
later  and  the  edges  sutured  together. 

The  fold  in  the  middle  of  the  lid  just  referred  to  can  be 
avoided  by  adopting  L.  Midler's  modification  of  the  oper- 
ation. When  the  keratome  is  introduced  the  lid  is  split 
further  toward  the  temporal  or  nasal  side  than  is  necessary 

1  von  Siklosy,  in  performing  Adams'  operation,  held  the  lid  between 
two  fixation  forceps  in  such  a  way  that  the  points  met  at  the  bottom  of 
the  conjunctival  sac. 


■  ^^ 


OPERATIONS  FOR  ECTROPION.  32? 

for  the  excision  of  the  triangle,  so  that  the  intermarginal 
incision  is  about  twice  as  large  as  in  Kuhnt's  operation. 
In  placing  the  sutures  the  excess  of  skin  (fulness)  is  then 
distributed  over  the  intermarginal  incision,  so  that  in- 
stead of  one  large  fold  a  number  of  small  ones  result  (see 
Plate  18,  Fig.  1,  before  the  operation  ;  Fig.  2,  immediately 
after  the  operation,  and  Fig.  3,  a  few  weeks  later),  which 
soon  become  obliterated.  But  in  doing  a  Midler's  modifi- 
cation I  found  it  necessary  to  see  that  the  tarsal  sutures 
which  take  the  place  of  the  excised  triangle  have  a  secure 
and  deep  hold  on  the  cartilage,  because  the  first  suture  of 
Kuhnt's  operation,  which  is  inserted  in  the  skin  and  is 
very  necessary  for  securing  firm  closure,  is  not  used  in  the 
modification. 

Another  modification  of  Kuhnt's  operation  was  recom- 
mended by  Dimmer.  By  combining  it  with  Dieffenbach's 
ectropion  operation — that  is,  excising  from  the  temporal 
end  of  the  lid  a  triangular  piece  of  skin  with  the  base  in 
the  prolongation  of  the  palpebral  fissure,  he  is  able  to  dis- 
place the  excess  of  skin  at  the  center  of  the  lid  (fulness) 
toward  the  temple,  after  splitting  the  lid  into  two  layers 
in  the  direction  of  the  temple  as  far  as  the  skin  triangle. 
That  is  to  say,  a  triangle  consisting  of  tarsus  and  conjunc- 
tiva is  excised  from  the  center  of  the  lid,  and  a  triangle 
of  skin  from  the  temporal  end  of  the  lid,  after  which  the 
skin  is  displaced  in  that  direction  so  that  no  puckering 
takes  place  at  the  center  of  the  lid. 

Cicatricial  ectropion  in  most  cases  presents  much  greater 
difficulties. 

In  a  general  way  the  principle  holds  good  that  no  attempt 
to  correct  the  condition  should  be  made  until  cicatrization 
is  complete,  because  the  subsequent  cicatricial  contraction 
would  otherwise  interfere  with  the  result  of  the  operation. 
Occasionally  mere  subcutaneous  division  of  a  few  cicatricial 
bands,  as,  for  example,  after  caries  of  the  edge  of  the 
orbital  margin,  may  improve  the  situation  ;  but,  as  a  rule, 
especially  in  extensive  scars  after  burns,  cauterization,  in- 
juries, necrosis,  caries  of  the  orbital  margin,  etc.,  the  entire 


328  OPERATIONS  ON  THE  EYE. 

Plate  18. 

Fig.  1. — Senile  ectropion  in  a  man  seventy-three  years  of  age.  The 
right  eye  has  been  running  for  two  years,  although  the  nasal  duct  is  per- 
meable. The  conjunctiva  of  the  lower  lid  is  greatly  swollen  and  red- 
dened from  catarrh. 

Fig.  2. — Same  eye  immediately  after  Kuhnt's  ectropion  operation  with 
L.  Müller's  modification. 

Fig.  3. — Same  eye  three  weeks  later,  after  recovery. 

scar  has  to  be  excised,  no  matter  bow  deep  it  extends  into 
the  tissue,  in  order  to  mobilize  the  lid.  The  latter  is  then 
restored  to  its  proper  position  and  the  excised  portion  cov- 
ered with  skin,  either  by  taking  a  pedunculated  flap  from 
the  immediate  neighborhood  or  skin  grafts  after  the  Thiersch 
method.  In  other  words,  it  is  frequently  necessary  in  these 
cases  to  restore  destroyed  parts  of  the  lid,  especially  the 
skin,  by  means  of  a  plastic  operation. 

Blepharoplastic  Operations. 

Whichever  method  is  employed  for  the  transplantation, 
the  first  rule  must  be  to  preserve  the  palpebral  margin  and 
the  adjoining  portion  of  the  lid  as  nearly  intact  as  possible, 
because  it  is  almost  indispensable  for  the  proper  framing 
of  the  palpebral  fissure. 

In  many  operations  of  this  kind  tarsorrhaphy,  or  tem- 
poral suturing  of  the  misplaced  lid,  becomes  necessary  as 
an  auxiliary  measure. 

First  of  all  the  lid  in  these  cases  of  cicatricial  ectropion 
must  be  rendered  perfectly  movable  by  separating  and 
excising  the  scars,  in  order  that  it  may  be  restored  as 
nearly  as  possible  to  its  normal  position.  In  order  suc- 
cessfully to  cover  the  defect  with  skin  grafts  after  the 
Thiersch  method,  it  is  absolutely  necessary  that  the  upper 
lid  be  drawn  down  over  the  lower  one,  or  the  lower  lid 
up  over  the  upper  one  (see  Plate  20).  This  is  best 
accomplished  by  means  of  a  few  skin  sutures. 

A  skin  flap,  whether  pedunculated  or  not,  in  contracting 
loses  at  least  ^  of  its  length  and  breadth  ;  there  is  a 
difference,    however,  between   contraction   of  the   trans- 


i-  *^? 


OPERATIONS  FOR  ECTROPION.  329 

planted  skin  and  contraction  of  the  underlying  layer.  If 
the  latter  consists  of  cicatricial  tissue,  it  will  continue  to 
contract  for  some  time  after  the  operation,  and  along  with 
it  the  superimposed  skin  will,  of  course,  also  contract,  so 
that  at  last  practically  nothing  will  be  left  of  it.  For 
this  reason  it  is  very  important  to  excise  as  much  as  pos- 
sible of  the  cicatricial  tissue  in  the  operative  field,  in- 
cluding that  contained  in  the  subcutaneous  cellular  tissue, 
and,  if  necessary,  to  extend  the  incision  as  far  as  the 
orbital  margin  and  the  tarso-orbital  fascia,  especially  if  it 
is  desired  to  employ  the  Thiersch  method. 

The  choice  between  the  latter  method  and  the  use  of  a 
pedunculated  flap  sometimes  depends  altogether  on  circum- 
stances. If  the  skin  surrounding  the  lids  is  also  distorted 
by  cicatricial  contraction,  as,  for  example,  in  the  case 
shown  on  Plate  22,  a  skin-grafting  flap  will  have  to  be  re- 
sorted to,  because  the  most  important  rule  in  employing  a 
pedunculated  flap  is  that  the  flap  shall  consist  as  much  as 
possible  of  normal  skin,  and  especially  that  the  insertion 
or  pedicle  shall  not  be  in  the  scar  tissue,  as  in  that  case 
the  flap  in  its  new  position  would  be  imperfectly  nourished 
and  in  danger  of  becoming  necrotic.  After  the  flap  has 
been  brought  into  its  new  position,  it  must  not  be  dis- 
torted and  the  sutures  must  not  be  placed  while  it  is 
stretched.  In  dissecting  the  flap  it  should  not  be  made 
too  thin,  but  should  retain  some  of  its  subcutaneous  fat, 
which  at  first  favors  nutrition,  although  it  later  atrophies. 
The  pedicle  of  such  a  flap  should  always  be  as  broad  as 
possible,  and  the  breadth  should  be  in  proportion  to  the 
length  (see  Plate  29).  It  is  always  important  to  see  that 
there  is  no  hair  included  in  the  flap,  as  it  continues  to 
grow  uninterruptedly  after  transplantation. 

Of  the  innumerable  methods  of  obtaining  a  peduncu- 
lated flap  and  placing  it  in  its  new  position — variations 
which  often  look  better  on  paper  than  in  vivo — Fricke's 
and  Dieffenbach's  blepharoplastic  methods  are  the  most 
important.  Fig.  134  illustrates  only  one  example  of  this 
method,  for  the  flap,  which  is  tongue-shaped  or  may  have 


330 


OPERATIONS  ON  THE  EYE. 


any  other  form,  may  also,  as,  for  example,  in  the  case  of 
the  lower  lid,  be. taken  from  the  skin  of  the  cheek,  or  the 
pedicle  of  a  flap  taken  from  the  brow  may  be  attached  to 
the  bridge  of  the  nose  (Plate  29).  Excessive  rotation 
should  always  be  avoided  in  bringing  the  flap  into  posi- 
tion. In  size  it  should  be  one-third  larger  in  every 
dimension  than  the  defect  which  it  is  to  cover.  The  fold 
which  is  sometimes  left  at  the  base  of  the  flap  after  rota- 
tion may  be  disregarded,  for  it  usually  flattens  out  later  or 
may  be  reduced  afterward  by  excision.     If  the  flap  has 


Fig.  134.— Fricke's  blepharoplastic  operation. 


been  made  a  little  too  small,  it  is  better  to  cover  as  much 
of  the  wound  as  possible  without  stretching  it,  and  cover 
the  remainder  with  skin  graft.  Any  attempt  to  increase 
the  size  of  the  flap  by  pulling  and  stretching  is  useless. 
It  should  be  securely  sutured  in  whatever  position  it 
assumes  when  it  is  applied  to  the  defect.  Hence,  care 
should  be  exercised  in  cutting  the  flap  to  see  that  it  fits 
as  accurately  as  possible  into  the  defect  which  is  to  be 
covered.  After  all  the  bleeding  has  been  stopped  the 
sutures  are  introduced  in  such  a  way  as  to  fasten  the  edges 
securely. 


OPE  RATIO  SS  FOR  ECTROPION. 


331 


In  this  method,  as  well  as  in  that  of  Dieffenbach,  the 
denuded  area  from  which  the  flap  has  been  taken  is  closed 
as  well  as  possible  with  sutures,  or  at  least  reduced  in  size 
as  much  as  possible  after  the  edges  have  been  undermined 
and  loosened.  The  rest  of  the  area  may  be  covered  with 
skin  grafts  after  the  method  of  Thiersch. 

With  Dieffenbach's  method  it  is  possible  to  cover  a 
triangular  defect  (Fig.  135)  by  taking  a  rhomboid  flap 
from  the  adjacent  area,  loosening  it  from  its  bed,  and  dis- 
placing it  laterally  until  it  covers  the  defect.  The  dotted 
tine  in  Fig.  135  indicates  the  upper  limit  of  the  Dieffen- 
bach flap  ;  but  as  the  flap  at  once  contracts  it  should  be 
made  a  little  larger  (solid  line).     The  broader  the  triangle 


Fig.  13").— Dieffenbach's  blepharoplastic  operation. 


to  be  covered — that  is,  the  larger  the  lower  angle — the 
higher  should  be  the  boundary  of  the  flap,  as  was  pointed 
out  by  von  Siklosy,  who,  like  von  Arlt  later  on,  also  ad- 
vised making  the  base  of  the  flap  narrower  than  the 
upper  limit,  which  in  fact  renders  rotation  of  the  flap 
easier.  By  extending  the  apex  of  Dieffenbach's  flap  fur- 
ther toward  the  temple,  the  flap  of  Szymanowsky's  modi- 
fication is  obtained. 

In  applying  a  bandage  during  the  after-treatment  of  lid 
operations  with  pedunculated  flaps,  care  must  be  exercised 
to  avoid  making  pressure  on  the  flap  with  the  bandage,  or 
distorting  it  when  the  dressing  is  changed.  The  wound 
as  well  as  the  palpebral  fissure  should  at  first  be  covered 


332  OPERATIONS  ON  THE  EYE. 

with  iodoform  gauze,  because  there  is  always  some  secre- 
tion. The  first  dressing  may  be  left  in  place  for  from  three 
to  four  days.  To  secure  perfect  rest  it  is  often  necessary  to 
bandage  the  other  eye  for  twenty-four  to  forty-eight  hours. 
Before  changing  the  dressing  it  should  be  thoroughly 
saturated  with  warm  sterilized  physiologic  salt  solution  or 
with  bichlorid  solution,  1  :  5000,  and  the  irrigation  is  con- 
tinued while  the  gauze,  which  adheres  to  the  wound,  is 
being  removed.  The  sutures  may  be  removed  in  from  five 
to  six  days,  after  which  a  dressing  with  borated  vaselin  or 
pure  vaselin  is  of  advantage. 

The  operative  treatment  of  cicatricial  ectropion,  as  well 
as  blepharoplastic  operations  in  general,  have  greatly  pro- 
fited by  Thiersch's  method  of  skin-grafting,  which 
may  be  used  either  to  cover  primary  defects  in  the  lid  or 
as  a  secondary  procedure  to  cover  the  denuded  area  from 
which  a  pedunculated  flap  has  been  taken,  as,  for  example, 
on  the  forehead,  cheek,  etc. 

Although  a  pedunculated  flap,  if  it  can  be  obtained  under  favorable 
circumstances,  is  to  be  preferred  to  a  flap  without  a  pedicle,  because  the 
result  is  more  prompt,  nevertheless  the  value  of  Thiersch's  method  of 
skin-grafting  is  considerably  greater  than  Yalude  and  Czermak  would 
have  us  believe.  I  can  not  help  agreeing  with  Kuhnt,  who  has  made  a 
special  point  of  practising  this  method,  Sachs,  and  certain  others,  that 
when  the  method  is  used  in  the  right  place  and  properly  carried  out  it 
yields  very  good  results.  Thiersch's  method  is  obviously  most  satisfac- 
tory in  cases  in  which  there  are  scars  in  the  neighborhood  of  the  affected 
eye,  making  it  difficult  or  even  impossible  to  obtain  a  pedunculated  flap. 
But  even  when  this  is  not  the  case,  the  grafting  operation  may  have 
certain  advantages  over  the  plastic  operation  with  a  pedunculated  flap, 
as,  for  example,  when  for  cosmetic  reasons  it  is  desired  to  avoid  disfig- 
uring the  parts  surrounding  the  eye  with  the  scar  left  by  the  removal 
of  a  pedunculated  flap,  as  these  scars  are  sometimes  quite  large. 

On  the  other  hand,  it  must  be  admitted  that  the  employment  of  non- 
pedunculated  flaps  is  often  followed  by  a  very  unpleasant  secondary 
contraction,  so  that  in  difficult  cases  with  severe  cicatrization  repeated 
grafting  often  becomes  necessary.  The  fault  in  these  cases,  however, 
lies  not  in  the  transplanted  skin,  but  in  the  fact  that  excision  of  the 
subcutaneous  cicatricial  tissue  has  not  been  sufficiently  thorough,  some-, 
times  because  it  is  impossible  to  do  so.  This  subcutaneous  cicatricial 
tissue  then  undergoes  further  contraction,  and  in  this  way  may  cause 
unpleasant  secondary  contraction  whether  the  flap  is  pedunculated  or 
not.  It  is  therefore  important  to  take  the  trouble  to  free  the  operative 
field  from  cicatricial  tissue  as  thoroughly  as  possible.     If  the  entire  tis- 


OPERATIONS  FOR  ECTROPION.  333 

sue  is  traversed  by  extensive  bands  of  scar  tissue,  Kuhnt's  plan  of  mak- 
ing a  number  of  linear  incisions  throughout  the  large  cicatricial  area — 
that  is,  dividing  it  into  small  independent  areas  by  intervals,  which  are 
free  from  cicatricial  tissue,  may  prove  useful. 

Skin-grafting  may  be  done  at  once  if  the  hemorrhage 
has  stopped,  or  at  all  events  in  a  few  days,  in  which  case 
the  area  will  have  to  be  anesthetized  by  subcutaneous  in- 
jection of  Cocain. 

In  my  experience  it  is  best  to  cut  as  large  and  thin  a 
piece  of  skin  as  possible  for  skin-grafting,  using  a  sharp 
planoconcave  knife  and  taking  the  grafts  from  the  inner 
surface  of  the  upper  arm,  while  an  assistant  seizes  the  limb 
on  the  outer  side  and  stretches  the  skin  as  much  as  possible 
by  pulling  on  the  soft  parts.  The  skin  as  well  as  the  knife 
should  be  well  moistened  with  physiologic  salt  solution,  so 
that  the  flap  will  lie  in  wrinkles  on  the  blade  instead  of 
sticking  to  it.  To  transfer  the  flap  to  the  wound,  the  end 
is  fixed  with  the  point  of  a  straight  needle  and  the  flap 
gradually  paid  out  by  slowly  withdrawing  the  knife  in  the 
direction  in  which  the  longitudinal  flap  is  to  be  laid  on 
the  wound.  In  this  way  the  possibility  of  applying  the 
flap  with  the  dermal  side  outward  is  avoided.  Thin  flaps 
are  better  because  they  are  less  apt  to  roll  up,  and  are 
therefore  more  easily  made  to  lie  smooth  on  the  wound. 
Large  flaps  after  the  Thiersch  method  have  this  advantage 
over  small,  very  thin  flaps  as  recommended  by  Eversbusch, 
that  the  area  of  skin-grafting  appears  less  tessellated. 

This  tessellated  appearance  is  often  quite  marked  after  transplantation 
with  small  flaps,  particularly  with  Reverdin's  method.  Thus,  in  the 
case  shown  in  Plate  22,  the  right  side  of  the  face,  which  had  been  scalded 
by  escaping  steam,  and  had  been  treated  elsewhere  by  Reverdin's  method 
three  years  before  the  picture  was  taken. 

Skin-grafting  also  has  the  advantage  that  it  can  be 
repeated  in  a  difficult  region  more  readily  than  trans- 
plantation of  a  pedunculated  flap,  and  with  patience  and 
perseverance  the  method  may  in  such  cases  in  the  end  lead 
to  a  permanently  good  result.  The  case  of  enormous  cica- 
tricial ectropion  shown  in  Fig.  1,  Plate  19,  in  which, 
owing  to  caries  of  the  orbital  margin  and  of  the  temporal 


334  OPERATIONS  ON  THE  EYE. 

Plate  19. 

Fig.  1.— Severe  cicatricial  ectropion,  the  result  of  caries  of  the  or- 
bital margin,  which  had  been  present  from  the  fifth  to  the  fourteenth  year 
of  life.  The  patient  is  a  male,  fifty-two  years  of  age.  As  a  result  of  the 
insufficient  covering  of  the  cornea  by  the  upper  lid  the  membrane  has 
become  opaque,  vascular  and  superficially  indurated  ;  the  eye,  as  a  result, 
became  blind  and  divergent.  The  temporal  portion  of  the  upper  lid  is 
adherent  to  the  upper  and  outer  edge  of  the  orbit,  which  presents  a  deep 
gap,  so  that  the  lid  is  inserted  far  back  in  the  cavity.  A  wide  strip  of  the 
conjunctiva  of  the  upper  lid  is  constantly  in  view  whenever  the  eyebrow 
is  slightly  raised.  Admitted  February  10, 1902.  Separation  of  the  upper 
lid  from  the  bone  to  permit  closing  the  palpebral  fissure  with  sutures. 
Second  operation  February  23 :  Skin-grafting  after  Thiersch  to  cover  the 
large  defect  with  skin  from  the  upper  arm.  Good  recovery;  discharged 
March  25.     The  eye  can  be  completely  closed. 

Fig.  2. — The  same  eye  six  months  later.  The  eye  can  not  be  closed 
entirely,  but  enough  for  practical  purposes.  The  patient  was  again  seen 
a  year  later  and  the  same  satisfactory  result  was  found. 

Plate  20. 

Fig.  1. — Cicatricial  ectropion  in  a  man,  nineteen  years  of  age,  who 
had  been  burned  with  molten  lead  at  the  upper  outer  angle  of  the  lid. 
First  operation  September  27,  1902 :  the  lid  was  separated  as  far  as  the 
tarso-orbital  fascia,  the  scar  excised,  and  the  upper  lid  drawn  down  and 
attached  to  the  cheek  with  a  suture  (Fig.  2).  Four  days  later  the  defect 
was  covered  with  skin  after  the  Thiersch  method. 

Fig.  2. — Showing  the  wound  before  the  skin-grafting. 

Plate  21. 

The  same  eye  two  weeks  later,  after  uninterrupted  recovery.  Closure 
of  the  palpebral  fissure  is  perfect. 

On  November  16th,  and  again  on  December  16th,  however,  a  secondary 
and  a  tertiary  operation,  although  not  as  extensive  as  the  first,  had  to  be 
performed,  after  which  the  condition  shown  in  Plate  21  persisted  perma- 
nently, although  in  ordinary  closure  of  the  eye  the  palpebral  fissure  gapes 
2  mm.  at  the  temporal  extremity. 


bone,  the  upper  lid  was  attached  far  back  on  the  defective 
orbital  margin,  was  relieved  by  an  operation  consisting  in 
separating  the  lid  and  drawing  it  down  as  far  as  possible. 
Almost  the  entire  skin  of  the  lid  had  to  be  made  anew,  as 
there  was  only  a  narrow  remnant  along  the  palpebral  edge. 
The  result  (Plate  19,  Fig.  2)  has  persisted  unchanged  for 
three  years. 


Htata 


./ 


mW 


ff" 


OPER  ATI  OSS  FOR  ECTROPION.  335 

In  the  case  of  the  patient  shown  on  Plate  20,  on  the  other 
hand,  three  operations  were  necessary  before  a  permanent 
cure  was  effected,  probably  because  I  operated  a  little  too 
early.  The  deep  burn  was  caused  on  the  10th  of  June, 
by  molten  lead,  and  the  ectropion  shown  in  Fig.  1  resulted. 
On  September  27th  the  lid  was  divided  so  as  to  separate 
the  palpebral  margin,  and  the  latter  drawn  down  as  far  as 
possible  and  secured  with  a  suture  (Plate  20,  Fig.  2).  On 
October  1st  the  defect  was  covered  after  the  Thiersch 
method,  and  on  October  15th  the  condition  shown  in  Plate 
21  had  developed.  Later,  however,  the  outer  portion  of 
the  lid  again  contracted,  so  that  the  skin-grafting  had  to  be 
repeated  on  Xovember  16th  and  again  on  December  16th, 
although  the  subsequent  operations  were  not  quite  so  ex- 
tensive a^  the  first.  The  final  result  corresponds  to  the 
condition  sbown  on  Plate  25.  The  patient  is  just  able  to 
close  the  palpebral  fissure.  It  would  perhaps  have  been 
better  to  excise  a  little  more  of  the  scar  in  the  prolongation 
of  the  eyebrow. 

A  case  like  the  one  shown  in  Plate  22  obviously  re- 
quires much  more  work.  Although  three  years  had  passed 
since  the  burn  was  sustained  and  cicatricial  contraction 
had  ceased,  the  scar  tissue  extended  far  into  the  tissue  and 
there  was  almost  no  skin  left  on  the  lid.  The  enormously 
lengthened  palpebral  edges  and  the  hypertrophied  conjunc- 
tiva gave  rise  to  further  difficulties,  so  that  the  result 
shown  on  Plate  23  was  not  achieved  until  the  skin  had 
been  loosened  five  times  and  the  skin-grafting  operation 
performed  each  time.  In  addition  Snellen's  suture  and 
tarsorrhaphy  had  to  be  resorted  to.  The  picture,  which 
was  painted  two  months  after  the  last,  and  one  year  after 
the  first,  operation,  shows  a  result  which  well  repaid  all  the 
trouble,  and  which,  as  subsequent  observations  proved, 
remained  permanent. 

In  this  case  it  would  have  been  impossible  to  use  a  pedunculated 
flap,  except  possibly  by  resorting  to  the  Italian  method,  which  consists 
in  training  the  patient  for  weeks  until  he  can  tolerate  having  his  arm 
fixed  with  bandages  or  a  plaster  cast  until  a  flap  taken  from  the  arm  has 


336  OPERATIONS   ON  THE  EYE. 

Plate  22. 

Enormous  cicatricial  ectropion  in  a  man,  twenty-three  years  of  age, 
who  had  suffered  a  deep  burn  on  the  right  side  of  the  cheek  three  years 
previously  from  escaping  steam,  and  had  been  treated  elsewhere  by  the 
transplantation  of  small  pieces  of  skin  after  the  Eeverdin  method  (with- 
out the  cooperation  of  an  oculist).  Slight  vascular  clouding  and  small 
reflecting  ulcers  on  the  lower  portion  of  the  cornea.  Enormous  elonga- 
tion of  the  palpebral  margin.  First  operation  February  14,1902;  both 
lids  were  divided  until  they  were  quite  movable  and  the  palpebral  fissure 
emild  be  closed  with  sutures  (without  freshening  up  the  edges).  Four 
days  later  the  large  wound  was  covered  with  skin  from  the  arm  after  the 
Thiersch  method.  In  March  and  April  the  operation  was  repeated  on  a 
smaller  scale  because  the  ectropion  continued  to  recur.  In  July  and  No- 
vember of  the  same  year  the  operation  was  again  repeated.  In  April 
tarsorrhaphy  at  the  outer  canthus  was  added. 

Plate  23. 

The  same  eye  on  February  5th,  three  months  after  the  last  operation. 
There  is  good  closure  of  the  palpebral  fissure.  Subsequent  observation 
showed  that  the  result  was  permanent. 


had  time  to  grow  fast  to  the  eyelid,  after  which  the  flap  is  divided.  In 
favorable  cases  this  requires  from  six  to  eight  days,  but,  unfortunately, 
the  discomfort  of  the  forced  position  of  the  arm  lasts  just  as  long. 

In  the  case  illustrated  on  Plate  24,  in  which  the  nasal 
portion  of  the  lid  had  been  destroyed  a  year  previously  by 
a  dog-bite,  and  the  remaining  temporal  portion  had  become 
the  seat  of  cicatricial  ectropion,  a  simpler  operation  suf- 
ficed to  correct  the  deformity.  Only  one  transplantation 
was  done,  the  deficiency  being  supplied  by  a  pedunculated 
flap  taken  from  the  upper  lid  after  the  method  of  Fricke. 
It  would  have  done  no  harm,  however,  if  another  attempt 
had  been  made  to  raise  the  lid  still  more,  but  the  patient 
was  satisfied.  The  grafted  skin  underneath  the  palpebral 
border  may  be  recognized  by  its  paler  color. 

Before  examining  more  closely  into  blepharoplastic 
operations  in  the  narrower  sense  of  the  term — that  is,  the 
entire  or  practically  entire  restoration  of  eyelids,  including 
the  conjunctival  portion — let  us  devote  a  moment's  atten- 
tion to  the  operative  correction  of  scars  on  the  inner  side 
of  the  lid  that  have  led  to  adhesion  of  the  lid  to  the  globe, 
or  Symblepharon.     The  condition  is  usually  due  to  the 


OPERATIONS  FOR  ECTROPION.  337 

adhesion  of  opposed  raw  surfaces  on  the  lid  and  on  the 
globe,  more  rarely  to  cicatricial  contraction  of  the  conjunc- 
tiva as  a  result  of  pemphigus  or  trachoma. 

If  the  adhesion  is  at  all  extensive  the  Operation  for 
Symblepharon  is  usually  a  very  difficult  undertaking, 
and  is  often  followed  by  only  a  moderately  good,  or  even 
an  unsatisfactory,  result.  But  in  this  condition,  also, 
matters  have  been  improved  since  the  invention  of  the 
method  of  transplantation,  especially  of  thin  pieces  of 
skin. 

Less  extensive  adhesions,  such,  for  example,  as  are  pro- 
duced by  burns  or  cauterization  of  the  lower  transitional 
fold  and  adjoining  palpebral  and  bulbar  conjunctiva,  are 
best  removed  by  the  method  of  von  Arlt,  as  shown  in 
Plate  26.  In  this  case  the  parts  had  been  converted  into 
an  extensive  eschar  by  the  burning  of  the  molten  iron 
(Plate  25,  Fig.  2),  and  this  had  been  followed  by  cicatri- 
cial adhesion  between  the  eyelid  and  the  globe,  extending 
as  for  as  the  cornea  (Plate  26,  Fig.  1).  Mere  division  of 
the  adhesion  and  the  insertion  of  a  disk  of  metal  or  glass 
to  prevent  the  parts  from  growing  together  again,  as  was 
formerly  done,  is  perfectly  useless  ;  nor  is  the  method  of 
any  avail  to  avoid  Symblepharon  in  recent  cases.  The 
process  of  adhesion  between  the  parts  is  so  powerful  that 
all  such  objects  are  gradually  forced  out,  and  it  is  there- 
fore absolutely  necessary,  after  the  adhesion  has  been 
divided,  to  see  that  both  the  palpebral  and  the  bulbar 
wound  are  covered  with  conjunctiva,  or  at  least  one  of 
the  wounds  should  be  so  protected  against  adhesion  with 
the  opposite  wound.  It  may  be  possible  to  cover  both 
wounds  by  reflecting  the  bridge  of  conjunctiva,  which  is 
put  on  the  stretch  as  the  lid  is  drawn  down,  toward  the 
transitional  fold  and  closing  the  bulbar  wound  by  a  hori- 
zontal row  of  sutures.  The  reflection  is  effected  by  means 
of  a  doubly  armed  suture,  which  is  drawn  through  the 
bridge  of  conjunctiva,  as  shown  in  Plate  26,  Fig.  1.  If 
the  conjunctiva,  as  sometimes  happens  in  these  cases,  is 
drawn  up  to  the  cornea  in  the  form  of  a  pterygium,  the 

22 


338  OPERATIONS  ON  THE  EYE. 

Plate  24. 

Fig.  1.— Cicatricial  Ectropion  after  a  Dog-bite :  The  patient,  a 
woman,  forty-nine  years  of  age,  had  been  bitten  a  year  previously  by  a 
large  dog,  so  that  the  lower  lid  hung  down.  The  family  doctor  cut  off  the 
dependent  portion  (evidently  the  nasal  half  of  the  lid),  on  the  ground 
"that  it  was  lost,  anyhuw."  That  was  a  great  mistake  ;  everythiug  ought 
to  have  been  at  once  carefully  sutured.  First  operation,  June  18,  1901 : 
Incision  of  the  inner  canthus,  3  mm.  from  the  edge  of  the  nasal  portion 
on  the  lower  lid  and  parallel  with  it,  extending  as  far  as  where  the  eye- 
lashes begin,  followed  by  loosening  of  the  lower  lid  until  closure  of  the 
palpebral  fissure  was  possible  without  exerting  much  friction.  From  the 
upper  lid,  which  has  an  abundance  of  flaccid  skin,  a  tongue-shaped  flap, 
3.5  cm.  in  width  and  |  cm.  long,  with  its  base  over  the  inner  canthus, 
was  cut  and  stitched  into  the  defect  on  the  lower  lid.  The  wound  on 
the  upper  lid  was  closed  with  a  suture.  As  the  flap  was  rather  long  the 
top  became  necrotic  and  sloughed  away,  so  that  on  July  16th  a  second 
operation  was  performed.  By  means  of  an  incision  along  the  lower  edge 
of  the  orbit  the  lid,  which  had  become  everted,  was  once  more  elevated, 
the  palpebral  fissure  again  closed  with  a  suture,  and  the  crescentic 
wound,  which  was  more  than  1  cm.  in  width,  covered  with  skin  after 
the  method  of  Thiersch.  Good  recovery  ;  discharged  August  30,  1901. 
Closure  of  the  palpebral  fissure  is  good. 

Fig.  2.— Condition  of  the  eye  fifteen  months  later  :  The  position  of  the 
nasal  portion  of  the  lower  lid  is  not  quite  correct,  but  the  patient  is  sat- 
isfied and  refuses  to  have  anything  more  done. 

suture  is  passed  through  the  traumatic  pterygium  after 
the  fold  of  conjunctiva  has  been  carefully  separated  from 
the  globe  (and,  if  necessary,  also  from  the  conjunctiva) 
without  denuding  any  more  tissue  than  is  absolutely  nec- 
essary. The  two  needles  are  inserted,  at  a  distance  of 
about  3  to  4  mm.  from  one  another,  into  the  transitional 
portion  of  the  lower  lid,  brought  out  through  the  latter, 
and  the  sutures  tied  over  a  little  roll  of  cotton.  The 
wound,  which  is  indicated  by  the  dotted  line,  is  then 
prepared  for  closure  by  means  of  two  incisions  running 
parallel  to  the  corneal  margin  and  by  undermining  the. 
palpebral  conjunctiva  laterally,  and  closure  effected  by 
means  of  2  or  3  horizontal  sutures.  As  the  bulbar  con- 
junctiva is  extremely  movable,  it  can  be  utilized  for  cov- 
ering a  defect  in  this  way  without  undue  stretching. 


^^1 


OPERATIONS  FOR  ECTROPION.  339 

In  every  case  of  extensive  adhesions  between  the  lids 
and  the  globe,  whether  they  be  due  to  injury  or  to  disease, 
the  best  practice  consists  probably  in  transplanting  a  thin 
piece  of  skin  obtained  from  the  inner  side  of  the  upper 
arm,  and  as  nearly  as  possible  free  from  hair — in  other  words, 
a  Thiersch  flap — for  the  purpose  of  covering  the  wound 
which  is  left  after  carefully  separating  the  lids  from  the 
globe.  In  many  cases  of  this  kind,  in  which  the  trans- 
parency of  the  cornea  has  been  destroyed  by  cicatrization, 
all  that  is  desired  is  merely  to  make  room  for  an  artificial 
eye.  In  view  of  the  numerous  and,  for  the  most  part, 
unfavorable  experiments  with  transplantation  of  mucous 
membrane  (from  the  mouth,  vagina,  rabbits,  etc.),  the 
transplantation  of  skin  is  very  much  to  be  preferred. 
Thin  pieces  of  skin,  as  nearly  as  possible  free  from  hair, 
when  transplanted,  gradually  assume  the  character  of 
mucous  membrane  and  are  well  tolerated  by  the  eye. 
Skin-grafting  on  the  inner  surface  of  the  lids  is,  however, 
more  difficult  than  on  the  outer  surface,  and  the  operator 
will  succeed  better  by  taking  advantage  of  an  observa- 
tion which  is  readily  made  in  transplanting  a  flap  of  skin 
after  the  Thiersch  method.  It  is  that  the  less  yielding 
the  soil  to  which  the  flap  is  to  be  transplanted,  the  more 
quickly  it  will  heal  and  the  less  will  be  the  secondary 
shrinking.  For  that  reason  large  denuded  areas  imme- 
diately overlying  bone  (as,  for  example,  the  large  wound 
in  the  forehead  in  the  patient  shown  in  Fig.  118)  heal 
very  rapidly  and  without  any  trouble.  In  the  case  of  a 
pedunculated  flap  the  necessary  support  may  be  given  to 
it  by  applying  the  unyielding  surface  to  the  other  side — 
that  is  to  say,  to  the  upper  instead  of  to  the  lower  side  of 
the  flap.  With  this  thought  in  view,  Hotz  and  May 
greatly  improved  the  method  of  transplanting  skin  into 
the  conjunctiva  by  using  a  rigid  support — Hotz  a  thin 
piece  of  lead  and  May  a  suitable  glass  prothesis — for  the 
flap  and  maintaining  it  in  a  stretched  condition. 

By  loosening  a  lower  lid  that  is  completely  adherent  to 
the  globe,  so  that  it  becomes  quite  movable  and  the  globe 


340  OPERATIONS   ON  THE  EYE. 

Plate  25. 

Fig.  1.— Complete  Symblepharon  and  almost  complete  ankylobleph- 
aron in  a  man  forty-two  years  of  age.  The  condition  resulted  from  a 
burn  of  the  eye  with  molten  iron.  Almost  the  entire  palpebral  as  well  as 
bulbar  conjunctiva  was  necrotic  when  the  patient  was  admitted  on  Jan- 
uary 15,  1903,  and  the  cornea  was  so  badly  burned  that  it  became  perfo- 
rated on  January  23d.  On  January  28th  the  globe  was  enucleated.  Tbe 
picture  shows  the  condition  of  the  orbital  region  at  the  beginning  of 
March.  On  March  13th  a  new  cavity  was  made  for  the  reception  of  an 
artificial  eye.  On  March  19th  an  attempt  was  made  to  close  the  cavity 
with  flaps  of  skin,  after  the  method  of  May  ;  but  the  result  was  unsatis- 
factory, and  on  March  30th  anotber  extensive  transplantation  was  per- 
formed. Again  the  transplanted  pieces,  for  the  most  part,  failed  to  adhere, 
and  the  pieces  tbat  did  adhere  contracted  subsequently,  so  that  on  April 
7th  the  condition  was  the  same  as  at  the  beginning  of  the  trouble. 

Fig.  2. — Eecent  burn  on  the  lower  portion  of  the  conjunctival  sac  with 
a  heated  piece  of  iron,  in  a  lad  seventeen  years  of  age.  The  accident 
happened  on  December  23,  1902. 


Plate  26. 

Figs.  1,  2. — The  Symblepharon  which  had  meanwhile  developed  was 
treated  by  operation  on  February  2b,  1903  (see  text). 


also  regains  its  mobility,  and  by  covering  the  large  wound 
which  occupies  the  inner  aspect  of  the  lid  and  the  lower 
portion  of  the  globe  with  flaps  after  the  Thiersch  method, 
the  latter  may  remain  in  good  apposition  with  the  globe 
and  the  edge  of  the  lid  if  the  eyes  are  properly  bandaged 
so  as  to  render  the  parts  absolutely  immovable,  especially 
if  the  flap  has  been  secured  to  the  conjunctiva  with  a  few 
sutures.  In  the  transitional  fold,  however,  there  is  noth- 
ing to  counteract  its  shortening,  and  from  that  point  con- 
traction goes  on  in  both  directions,  and  is  so  marked  that 
the  transplanted  piece  ultimately  stretches  from  the  edge 
of  the  lid  to  the  globe,  and  the  original  condition  is  re-' 
stored. 

It  is  possible  with  this  method  of  skin-grafting  to  secure 
the  flap  in  the  transitional  fold  by  means  of  a  loop  or 
bridle  suture  (which  von  Stellwag  used  for  the  transplan- 
tation of  mucous  membrane)  and  thus  keep  it  in  close 


) 


m 


^ 


''  mm 


OPERATIONS  FOR  ECTROPION.  341 

contact  with  its  support.  For  that  purpose  the  two  needles 
of  a  doubly  armed  suture  are  introduced  through  the 
superimposed  flap  and  through  the  entire  lid,  at  not  too 
great  a  distance  from  one  another,  and  the  sutures  tied  on 
the  outside  of  the  skin,  over  a  small  roll  of  cotton  or  a 
piece  of  drainage  tube.  Two  or  three  additional  sutures 
may  be  introduced  in  the  same  way  alongside  the  first. 
These  sutures  draw  the  transplanted  flap  firmly  into  the 
transitional  fold.  That  a  suture  of  this  kind  is  useful 
even  in  transplantation  of  mucous  membrane  is  shown  by 
a  case  of  Axenfeld's,  in  which  he  succeeded  by  a  plastic 
operation  in  restoring  the  entire  conjunctival  sac  after 
complete  cicatricial  Symblepharon  and  ankyloblepharon, 
although  it  required  four  operations,  each  lasting  from  two 
and  one-half  to  three  hours.  He  used  mucous  membrane 
from  the  lips  and  mouth. 

Hotz's  lead  plate,  which  can  be  perfectly  adapted  to 
the  operative  field,  offers  the  great  advantage  of  pressing 
the  transplanted  flap  evenly  over  the  wound  and  rendering 
it  immovable.  From  a  piece  of  lead  foil  about  0.5  mm. 
thick  (or  a  piece  of  tinfoil,  as,  for  example,  a  piece  of  a 
bottle-cap)  a  suitable  piece,  usually  of  a  crescentic  form,  is 
cut  out  and  bent  into  the  proper  shape ;  a  few  holes  are 
then  bored  into  the  edge  that  is  to  fit  on  the  palpebral 
margin  for  the  sutures  with  which  it  is  to  be  secured  after 
the  transplanted  piece  of  cutis  has  been  placed  in  position. 
The  other  edge  of  the  lead  plate  is  placed  in  the  transi- 
tional fold.  The  skin  itself  need  not  be  fixed  Avith  sutures. 
On  the  other  hand  it  may  be  well  to  close  the  palpebral 
fissure  for  a  few  days  with  sutures,  and  to  keep  an  occlu- 
sive dressing  on  the  other  eye  for  two  days. 

May's  method  was  used  by  Widmark  in  a  number  of 
eases  (reported  by  Landstrom)  with  good  result.  After 
the  lids  have  been  separated  from  the  globe  and  the  hemor- 
rhage has  been  arrested,  the  glass  eye,  covered  with  skin 
flaps  after  the  Thiersch  method,  is  introduced  into  the 
conjunctival  sac,  the  lids  are  united  with  sutures,  and  the 
dressing  applied.     The  sutures  may  be  removed  from  the 


342  OPERATIONS  ON  THE  EYE. 

Plate  27. 

Large  carcinoma,  which  has  evidently  started  from  the  inner  canthus 
of  the  eye  (a  small  carcinomatous  proliferation  is  also  seen  on  the  left 
side).  The  patient,  who  had  been  referred  to  the  clinic  by  his  physician, 
has  not  been  able  to  make  up  his  mind  to  submit  to  an  operation.  The 
tumor  forms  a  mass  1  to  2  cm.  thick  and  somewhat  depressed  at  the  center, 
where  it  bleeds  readily.  By  drawing  the  tumor  down  the  cornea  can  be 
seen  behind  the  upper  portion.  Below,  it  is  adherent  to  the  skin  of  the 
cheek,  into  which  it  has  proliferated. 

First  operation  November  22,  1902  :  Extirpation  of  the  small  tumor  on 
the  left  side  and  the  large  tumor  on  the  right  side.  The  wound,  which 
is  the  size  of  a  small  palus,  is  seen  to  be  intact  and  freely  movable  ;  the 
lower  lid  is  altogether  deficient ;  the  temporal  third  of  the  upper  portion 
was  saved  and  drawn  over  the  cornea  as  well  as  possible  and  united  to  the 
temporal  portion  of  the  lower  lip  of  the  wound  and  to  the  palpebral  con- 
junctiva, which  had  formed  a  border  0.5  cm.  in  width,  surrounding  the 
cornea  toward  the  nasal  side.  Four  days  later  we  covered  the  entire 
wound  with  skin  obtained  from  the  arm  after  the  Thiersch  method,  with 
a  good  result.  The  remains  of  the  upper  lid  gradually  came  down  lower 
and  lower  over  the  cornea,  which  remained  entirely  intact.  Below  the 
cornea  was  a  strip  of  free  palpebral  conjunctiva,  which  on  December  15th 
was  reflected  upward  and  covered  on  its  outer  side  with  a  flap  after  the 
Thiersch  method.  At  the  same  time  the  outer  canthus  was  somewhat 
enlarged  by  an  incision  and  covered  with  flaps  of  skin. 

Plate  28. 

Shows  the  patient's  condition  when  he  was  discharged  cured  on  De- 
cember 31,  1902.  Further  attempts  to  correct  and  expose  the  cornea  were 
put  off  to  another  time. 

lids  after  five  days,  but  the  glass  plate  is  allowed  to  remain 
a  few  days  longer.  The  method  is  probably  best  adapted 
for  eyes  with  a  leukomatous  cornea.  The  procedure,  like 
that  of  Hotz  with  a  lead  plate,  may,  under  certain  circum- 
stances, have  to  be  repeated  in  order  to  increase  the  depth 
of  the  conjunctival  sac.  In  the  case  illustrated  in  Plate 
25,  Fig.  1,  there  was  complete  Symblepharon  with  large 
ankyloblepharon  secondary  to  an  extensive  burn  of  the  eye 
and  enucleation  of  the  globe.  Two  operations  after  May 
did  not  suffice  to  create  enough  space  for  an  artificial  eye. 
In  this  case,  however,  the  difficulties  were  about  as  great 
as  could  be  imagined,  and  for  external  reasons  the  opera- 
tion unfortunately  could  not  be  continued. 


:v 


s. 


fc^ 


I 


^ 


I 


) 


OPERATIONS  FOR  ECTROPION.  343 

When  the  surgeon  is  confronted  with  the  task  of  per- 
forming a  blepharoplastic  operation  in  the  narrow 

sense  of  the  word — that  is,  forming  a  complete  lid  after 
destruction  by  malignant  disease,  injury,  gangrene,  etc. — 
the  difficulties  are  multiplied,  because  both  the  anterior 
and  the  posterior  aspects  of  the  lid  have  to  be  newly 
formed. 

Such  cases,  especially  when  the  lower  lid  is  deficient, 
may  be  treated  by  Eversbusch's  operation,  which  is  then 
performed  in  two  sittings.  At  the  first  sitting  a  flap  of  a 
suitable  size  is  formed  from  the  neighboring  skin  (after 
Fricke).  The  dorsal  side  of  this  flap  and  the  wound  pro- 
duced by  its  excision  are  covered  with  epidermis,  the  latter 
covered  with  protective  silk  or  rubber  paper,  and  the  flap 
returned  to  its  natural  position.  After  the  transplanted 
piece  of  skin  has  grown  fast,  the  flap  is  inserted  in  place 
of  the  lid  that  has  been  destroyed,  after  freshening  up  the 
orbital  margin  as  required.  Later,  Eversbusch  recom- 
mended that  the  posterior  surface  of  the  flap  be  covered 
with  mucous  membrane  obtained  from  the  pharynx  of  the 
rabbit. 

If  the  transitional  portions  of  the  lowrer  or  upper  lid 
are  preserved  and  the  other  lid  is  in  good  condition,  the 
latter  may  be  used  for  closing  the  gap  after  the  method 
suggested  by  Landolt.  For  example,  if  the  lower  lid  is 
to  be  restored  the  intact  upper  lid  is  divided  into  two 
layers,  an  anterior  layer  consisting  of  cutis  and  muscle, 
and  a  posterior  layer  consisting  of  tarsus  and  conjunctiva. 
The  anterior  layer  is  then  converted  into  a  bridged  flap  by 
a  curved  incision  along  the  orbital  margin,  and  this  flap  is 
drawn  down  until  the  upper  edge  of  the  bridge  is  at  the 
same  level  as  the  lower  edge  of  the  posterior  layer.  What 
remains  of  the  lower  lid  is  split  into  two  layers,  and  the 
lower  edge  of  the  bridge  flap  formed  from  the  upper  lid  is 
inserted  between  the  two  layers  and  secured  with  sutures, 
the  bridge  flap  having  first  been  freshened  up  on  its  ante- 
rior side  also.     After  the  eye  has  been  kept  closed  for 


344  OPERATIONS  ON  THE  EYE. 

Plate  29. 

The  same  patient  after  the  carcinoma  had  recurred  and  had  again 
been  removed.  On  January  26,  1903,  he  returned  with  a  recurrent 
growth  the  size  of  a  hazel-nut  at  the  inner  canthus,  which,  by  the  time 
he  could  be  admitted  and  operated  upon  (February  3d),  had  attained  the 
size  of  a  walnut.  On  that  date  I  did  a  radical  extirpation,  covering  the 
wound  with  a  large  dap  taken  from  the  forehead,  with  its  base  at  the  root 
of  the  nose,  and,  after  splitting  it  at  the  end,  secured  it  with  sutures  in 
such  a  way  as  to  restore  the  nasal  halves  of  the  upper  and  lower  lids. 
In  order  to  form  a  better  inferior  covering  for  the  cornea  I  cut  a  small 
flap,  with  its  base  directed  toward  the  temple,  from  the  surrounding  skin 
and  stitched  it  to  the  lower  portion  of  the  skin  flap.  The  areas  from 
which  the  large  forehead  flap  and  the  smaller  flap  had  been  taken  were 
covered  on  February  13th  with  skin  taken  from  the  arm  after  Thiersch, 
the  wound  on  the  forehead  having  previously  (at  the  operation)  been 
reduced  as  much  as  possible  by  means  of  sutures.  The  picture  shows  the 
condition  of  the  eyes  in  the  middle  of  March.  The  lower  edge  of  the 
cornea  is  not  covered,  and  therefore  shows  a  small  marginal  ulcer  at  that 
point.  The  patient  had  to  be  discharged  on  March  13th,  and  further  pro- 
cedures to  correct  the  condition  were  put  ofl"  until  another  time. 

Toward  the  end  of  March  and  in  April  another  attempt  was  made  to 
utilize  the  small  remainder  of  conjunctiva  for  small  pedunculated  flaps 
to  cover  the  lower  portion  of  the  cornea.  The  attempt  was  so  successful 
that  the  patient's  discomfort  was  relieved,  and  on  September  23d  he 
showed  visual  power  of  fa  when  the  upper  lid  was  drawn  up  or  he  put 
his  head  back.  No  local  recurrence  of  the  tumor  has  appeared  so  far,  but 
in  September,  1903,  a  glandular  carcinoma  had  to  be  removed  from  the 
angle  of  the  jaw  in  the  surgical  clinic. 


several  months  a  new  palpebral  fissure  is  made  by  incising 
the  membrane. 

If  the  palpebral  portions  of  both  lids  are  absent  the 
remains  of  the  transitional  portions  are  also  divided  into 
two  layers;  but  in  this  case  the  posterior  layer  of  the 
lower  lid  must  be  freed  in  its  transitional  portion  by  an 
incision  along  the  orbital  margin,  so  as  to  make  it  possible 
to  draw  it  up.  The  eye  is  then  covered  with  a  membrane 
consisting  of  the  4  layers  of  the  2  remnants  of  the  lids 
which  have  been  drawn  apart  and  the  edges  of  which 
overlap.  These  4  layers  in  alternation  present  a  wound 
surface   first   posteriorly  and  then  anteriorly.     The  latter 


f 


i 


OPERATIONS  FOR  ECTROPION.  345 

would  nowadays  be  covered  with  flaps  after  the  Thiersch 
method. 

The  same  method  of  splitting  into  layers  and  inter- 
leaving the  layers  may  also  be  done  in  a  horizontal  direction, 
after  Landolt. 

Operations  on  the  Conjunctiva. 

The  most  important  operations  on  the  conjunctiva  that 
still  remain  to  be  considered  have  to  do  chiefly  with  the 
surgical  treatment  of  trachoma. 

As  in  all  other  operations  on  the  conjunctiva,  the  neces- 
sity of  sparing  the  membrane  as  much  as  possible  must  be 
constantly  borne  in  mind. 

(1)  It  is  therefore  better  not  to  excise  the  transitional 
folds  unless  they  are  so  thickly  covered  with  granules  as 
to  leave  hardly  any  normal  tissue  between  them  (Galezowski, 
Heisrath,  and  others).  In  such  cases  from  five  to  eight 
needles  threaded  with  silk  sutures  are  introduced  vertically 
into  that  part  of  the  conjunctiva  which  is  to  be  removed, 
the  area  is  marked  out  with  a  scalpel,  and  separated  from 
the  subjacent  tissue  with  scissors.  The  sutures  are  then 
drawn  through  and  tied. 

If  the  granules  are  not  very  thickly  scattered  over  the 
mucous  membrane,  it  is  better  to  destroy  them  with  the 
(2)  galvanocautery,  or  to  resort  to  (3)  scarification  and 
brushing  out  with  a  wire  brush  like  von  Schroder's,  for 
example  (Fig.  140),  or  still  better  (4)  crush  them  out. 

The  latter  method  may  be  combined  with  scarification, 
but,  as  a  rule,  this  is  not  necessary,  because  the  crushing 
instruments  usually  have  sufficient  force  to  express  the 
granules  from  the  tissues.  To  the  earliest  instruments  of 
this  kind,  designed  by  Prince  (similar  to  the  forceps  shown 
in  Fig.  139)  and  Noyes,  were  soon  added  Knapp's  roller 
forceps  (Fig.  136)  and  Rust's  modification  of  it  (Fig.  137). 
Then  appeared  Dohnberg' s  clamp  (Fig.  138)  and  Graddy's 
instrument,  which  is  in  every  way  similar  to  it,  von 
Schroder's  (Fig.  139)  and  Kuhnt's  expressors  with  fenes- 
trated end-plates.      The  longitudinally  serrated  rolls  of 


346  OPERATIONS  ON  THE  EYE. 

Figs.  136-140. — Instruments  for  the  treatment  of  trachoma : 
Fig.  136. — Knapp' s  roller  forceps. 
Fig.  137. — Eust's  roller  forceps. 
Fig.  138. — Dohnberg' s  clamp  forceps. 
Fig.  139. — von  Schroder's  clamp  forceps. 
Fig.  140. — von  Schroder's  wire  brush. 

Knapp's  forceps  and  Rust's  modification — the  latter  enables 
one  to  get  a  better  hold  of  the  most  lateral  portions  of  the 
transitional  folds — must  be  kept  in  perfect  condition  and 
guarded  against  rust,  because  it  is  important  that  the  rollers 
should  rotate  properly ;  hence  they  should  be  cleansed 
immediately  after  being  used. 

After  the  eye  has  been  thoroughly  anesthetized  by  means 
of  cocain  and  adrenalin,  the  roller  and  clamp  forceps  are 
applied  to  the  everted  lids.  [Guttinan  recommends  a  form 
of  subconjunctival  infiltration  anesthesia  with  a  cocain 
and  salt  solution. — Ed.]  The  transitional  fold  of  the 
upper  lid  is  seized  with  the  fixation-forceps  and  drawn 
away  from  the  eye,  so  that  the  entire  lid  may  be  seized, 
between  the  ends  of  the  instrument.  On  the  lower  lid  the 
fixation-forceps  can  be  dispensed  with.  The  affected 
portion  of  the  tissue  is  manipulated  by  drawing  it  out  with 
the  instrument  until  it  is  free  from  granules.  The  angles 
of  the  lid  and,  if  necessary,  the  caruncle  must  be  carefully 
attended  to.  If  the  tarsal  conjunctiva  contains  granules, 
one  blade  of  the  roller  forceps  is  applied  to  the  skin  of  the 
lid  and  the  other  to  the  conjunctiva,  and  the  instrument 
passed  over  the  lid  several  times  in  this  way  until  all  the 
granules  have  disappeared. 

In  all  these  expressing  operations  it  is  a  wise  precaution 
to  wear  protective  spectacles,  so  as  to  guard  against  any 
of  the  infectious  material  entering  the  eyes.  I  have  heard 
that  in  Russia  physicians  have  become  infected  while  per- 
forming this  operation. 

No  bandage  is  required  after  the  operation,  and  the 
patient,  as  a  rule,  feels  very  much  relieved.  [Immediately 
after  an  operation  for  expression,  with  forceps,  of  trachoma 
granules,  iced  compresses  are  of  service.     The  subsequent 


OPERATIONS  ON  THE  LACRIMAL   ORG  ASS.      347 

140 


treatment  with  a  bichlorid  (1  :  7000)  lotion  and  argyrol  or 
protargol,  to  lessen  discharge,  is  important. — Ed.] 

D.  OPERATIONS  ON  THE  LACRIMAL  ORGANS. 

In  the  great  majority  of  cases  operative  interference  is 
required  to  correct  abnormalities  in  the  flow  of  the  tears 
into  the  nose,  usually  as  a  result  of  narrowing  of  the  nasal 
duct  and  its  consequences. 


348  OPERATIONS  ON  THE  EYE. 

Figs.  141-148.— Instruments  for  operations  on  the  lacrimal  passages  : 

Fig.  141.— Retractor  after  L.  Müller. 

Fig.  142.— Glass  syringe  with  cannula. 

Fig.  143. — Blunt  (conical)  probe  for  dilating  the  canaliculus. 

Fig.  144. — Weber's  knife  for  splitting  the  canaliculus,  curved. 

Fig.  145. — Same  instrument,  straight. 

Fig.  146. — Bowman's  sound,  before  it  has  been  bent  for  use. 

Fig.  147. — Bowman's  sound,  after  it  has  been  bent  for  use. 

Fig.  148.— Von  Wecker's  hollow  sound. 


1.  Simple  eversion  of  the  lower  lacrimal  punc- 
tum when  the  lacrimal  passages  are  otherwise  normal 
may,  however,  cause  lacrimation  and  prove  the  beginning 
of  an  ectropion.  If  the  lower  punctum  is  not  below  the 
level  of  the  tear-lake,  the  accumulated  lacrimal  fluid  is 
very  apt  to  run  over,  and  the  patient  keeps  wiping  his 
eye,  which  he  does,  as  a  rule,  in  an  outward  and  down- 
ward direction.  The  lower  lid  is  thus  dragged  downward 
and  outward,  and  if  the  tissues  are  flaccid  from  old  age 
this  may  lead  to  the  production  of  ectropion,  assisted  as  it 
is  by  the  shortening  of  the  skin,  which  is  caused  by  the 
excessive  maceration  and  excoriation.  A  vicious  circle 
is  thus  established,  by  which  a  simple  eversion  of  the 
lower  lacrimal  punctum  may  lead  to  ectropion. 

For  this  reason  the  anomaly,  which,  as  a  rule,  is  the 
result  of  the  relaxation  of  the  lid,  ought  to  be  removed  as 
soon  as  possible,  first,  by  ordering  the  patient  always  to 
wipe  his  eye  in  an  inward  and  upward  direction  ;  secondly, 
by  splitting  the  lower  canaliculus.  The  splitting  must 
be  done  in  such  a  way  that  the  slit  is  submerged  in  the 
tear-lake,  and,  hence,  the  posterior,  and  not  the  upper,  wall 
of  the  canaliculus  must  be  divided.  After  the  lower 
canaliculus  lias  been  somewhat  dilated  with  a  conical 
probe  (Fig.  143)  in  a  manner  to  be  described  presently 
(Figs.  149,  150),  one  of  the  blades  of  a  slender,  blunt  pair 
of  scissors  is  inserted  into  the  canaliculus,  which  is  at  the 
same  time  drawn  well  away  from  the  globe.  The  edge  of  the 
scissors  blade  is  then  turned  toward  the  posterior  wall  of 
the  canaliculus,  so  that  the  other  blade  comes  close  against 


142  143         \    144       (    145  1 


iX 


349 


350  OPERATIONS  ON  THE  EYE. 

the  globe,  and  the  canal  divided.  After  the  lid  has  been 
allowed  to  resume  its  normal  position,  the  slit  should  be 
directed  downward  toward  the  lower  portion  of  the  car- 
uncle. 

This,  however,  is  not  enough ;  for  the  wound  would 
simply  grow  together  again.  In  order  to  keep  it  open  it 
must  be  dilated  several  times  with  a  probe  during  the 
next  few  days,  or,  what  is  still  better,  Hoffmann's  sug- 
gestion of  cutting  off  one  edge  of  the  slit  with  the  scis- 
sors and  thus  converting  the  canal  into  a  groove  may  be 
adopted  after  the  canaliculus  has  been  opened. 

2.  With  regard  to  dacryostenosis,  which  is  such  a 
common  trouble,  I  am  convinced,  after  years  of  experience, 
that  operative  treatment,  which  includes  dilatation  with 
the  probe,  should  not  be  resorted  to  until  the  more  con- 
servative treatment  by  the  injection  of  medicated  solutions 
and  the  treatment  of  the  nasal  cavity,  if  the  latter  is  also 
diseased,  have  failed  to  effect  a  cure.  I  am  therefore  firmly 
opposed  to  the  employment  of  the  sound  from  the  very 
beginning  as  a  matter  of  routine  (see  my  Atlas  and  Epitome 
of  External  Diseases  of  the  Eye,  p.  89). 

Irrigation  of  the  lacrimonasal  duct,  which  has  already 
been  discussed  as  a  preliminary  measure  in  major  opera- 
tions (p.  57),  is  performed  with  a  syringe  armed  with  a 
delicate  cannula.  A  glass  syringe  (Fig.  142)  is  the  best. 
In  order  that  the  cannula  may  be  readily  introduced  into 
the  lower  canaliculus,  the  latter  is  cautiously  dilated  with 
a  blunt  probe  (Fig.  143).  In  the  case  of  sensitive  per- 
sons a  few  crystals  of  pure  cocain  should  be  applied  to  the 
lacrimal  punctum  a  little  while  before  the  operation  is 
begun.  The  probe  must  be  introduced  in  a  direction  cor- 
responding to  that  of  the  canaliculus — that  is,  at  first  ver- 
tically (Fig.  149)  for  a  distance  of  from  1  to  2  mm.,  and 
then  brought  into  the  horizontal  plane  (Fig.  150)  and 
cautiously  advanced  with  a  slight  boring  movement.  The 
syringe,  which  has  been  previously  filled  with  the  fluid, 
is  then  at  once  introduced,  also  at  first  in  a  vertical  direc- 
tion, and  the  contents  gradually  discharged  into  the  lacri- 


OPERATIONS  ON  THE  LACRIMAL   ORGANS.      351 

mal  sac  by  pushing  on  the  piston  (Fig.  151).  The  patient 
should  incline  the  head  slightly  forward  to  allow  the  fluid 
to  run  out  through  the  nose. 

Even  this  simple  procedure  is  not  always  quite  easy, 
and  an  inexperiencecl  operator  is  likely  to  make  a  false 
passage  with  the  conical  probe  or  with  the  cannula — that 
is,  push  it  into  the  tissue,  which,  if  bichlorid  of  mercury 
is  used,  is  followed   by  a   severe  and   painful  swelling  of 


Fig.  149.— Dilation  of  the  lower  lacrimal  canaliculus  :  First  step. 

the    tissue   surrounding   the    canaliculus,   lasting    several 
days. 

For  this  reason,  if  the  operator  is  not  quite  sure  of 
himself  he  should  use  a  physiologic  saline  solution  when 
he  performs  his  first  irrigation.  Medicated  solutions  that 
may  be  recommended  are  bichlorid  of  mercury,  1  :  5000 
up  to  1  :1000;  protargol,  5  to  10  per  cent.  ;  [argyrol,  10 
to  25  per  cent. — Ed.]  ;  silver  nitrate  or  zinc,  1  per  cent., 
etc.      An  important  precaution  consists  in  injecting  the 


352 


OPERATIONS  ON  THE  EYE. 


Fig.  150.— Dilation  of  the  lower  lacrimal  canaliculus :  Second  step. 

canal  with  adrenalin,  which  causes  some  dilation  and  thus 
affords  an  easier  passage  not  only  for  the  medicated  solutions, 


Fig.  151.— Injecting  the  nasal  duct. 


but  also  for  the  probe.  In  the  case  of  sensitive  persons  it 
is  best  to  begin  by  injecting  a  few  drops  of  cocain  solution, 
as  the  medicated  solutions  are  then  less  unpleasant. 


OPERATIONS  ON  THE  LACRIMAL   ORGANS.     353 

3.  Dilation  of  the  nasal  dnct  by  means  of 
sounds  should  be  left  to  the  practiced  specialist,  for  it  is 
a  useless  procedure  unless  the  technic  is  perfect  and  due 


Fig.  152.— Dilation  of  the  nasal  duct  with  the  sound:  Introduction  of  the 
sound  into  the  tear  sac. 

caution  is  observed.  It  is  better  to  use  the  upper  canal- 
iculus, because  the  introduction  of  the  sound  causes  less 
distortion  than  in  the  lower  canaliculus.  A  day  before 
the  sound  is  introduced  the  canaliculus  is  to  be  split  with 

23 


354 


OPERATIONS  ON  THE  EYE. 


a  bent  or  straight  Weber's  knife,  if  necessary,  after  pre- 
liminary cocainization  and  dilation  with  the  conical  probe. 
The  sound  selected   for  the  dilation   should    not  be  too 


Fig.  153.— Dilation  of  the  nasal  duct  with  the  sound :  Introduction  of  the 
sound  into  the  lacrimonasal  duct. 


small ;  Bowman's  No.  3  or  4  (Fig.  147)  is  the  best. 
Before  the  sound  is  introduced  a  few  drops  of  a  2  to  5  per 
cent,  solution  of  cocain,  followed  by  adrenalin,  or  the  two 
together  are  injected  into  the  duct,  and  if  the  latter  is 


OPERATIONS  ON  THE  LACRIMAL   ORG  ASS.      355 


Fig.  154.— Dilation  of  the  right  nasal  duct  with  a  sound. 


356  OPERATIONS  ON  THE  EYE. 

Plate  30. 

Fig.  1. — Extirpation  of  the  tear  sac  in  a  woman,  thirty- three  years  of 
age,  who  states  that  the  left  eye  began  to  run  six  months  previously. 
Swelling  (ectasia)  of  the  tear  sac  and  suppuration  began  four  months 
previously.  The  patient  would  not  hear  of  extirpation  of  the  tear  sac, 
which  was  proposed,  and  had  herself  treated  elsewhere  for  three  months 
by  sounding.  She  also  said  an  incision  and  curettage  had  been  performed. 
As,  however,  the  purulent  catarrh  of  the  tear  sac  persisted,  she  returned 
to  the  clinic  on  October  28,  1902,  and  was  relieved  of  her  tear  sac  under 
local  anesthesia  with  a  eucain-cocain  solution.     Normal  recovery. 

Plate  30. 

Fig.  2. — The  extirpated  tear  sac,  which  had  probably  not  been  reached 
by  the  incision  and  curettage  referred  to. 

still  permeable,  so  that  the  solution  flows  out  through  the 
nose,  this  procedure  will  materially  facilitate  the  introduc- 
tion of  the  sound  and  make  the  operation  much  more 
bearable  to  the  patient. 

As  the  sound  is  introduced  into  the  canaliculus  and  tear 
sac  the  upper  lid  must  be  drawn  well  outward — that  is,  the 
canaliculus  must  be  straightened  and  put  on  the  stretch 
(Fig.  152).  The  sound  must  not  be  brought  into  the  ver- 
tical position  until  the  point  has  evidently  touched  the 
bony  nasal  wall  of  the  tear  duct.  As  the  sound  passes 
into  the  lachrimonasal  duct  (Fig.  153),  special  caution 
should  be  used  and  the  instrument  should  be  advanced 
very  slowly,  because  it  is  at  this  junction  that  strictures 
are  quite  often  found.  During  this  step  the  skin  above 
the  tear  sac  should  be  drawn  well  upward  with  the  thumb 
of  the  left  hand,  while  the  rest  of  the  hand  is  used  to 
steady  the  patient's  head.  In  sounding  the  right  canal- 
iculus the  operator  should  stand  behind  the  patient  (Fig. 
154). 

After  the  sound  has  successfully  reached  the  nasal  duct, 
it  is  very  cautiously  introduced  along  the  passage,  and 
withdrawn  from  time  to  time  for  the  purpose  of  smoothing 
out  any  folds  of  mucous  membrane.  It  is  utterly  wrong 
to  employ  force  when  it  is  found  impossible  to  introduce  it 
any  further.     Instead  it  should  be  allowed  to  remain  in 


t 


OPERATIONS  ON  THE  LACRIMAL   ORGANS.     357 

place  about  half  an  hour  and  then  removed,  and  another 
attempt  made  after  two  or  three  days  to  push  it  further 
along,  which  attempt  quite  often  proves  successful.  At 
the  second  sitting,  also,  the  sound  should  not  be  carried 
farther  than  it  will  go  with  gentle  pressure.  If  the  oper- 
ator gets  the  impression  that  the  sound  is  completely 
through  the  canal  (so  that  the  leaf  stands  at  the  inner 
extremity  of  the  eyebrow),  he  should  make  sure  of  the 
fact  by  injecting  some  fluid.  The  sound  is  carefully  with- 
drawn after  half  an  hour,  the  patient's  head  being  firmly 
fixed  with  the  left  hand  during  the  process,  and  von 
Wecker' s  hollow  sound  (Fig.  148)  is  introduced  into  the 
canal  in  the  same  way  as  the  solid  sound.  The  wire  is 
then  withdrawn  and  fluid  injected  with  a  glass  syringe. 
By  slowly  withdrawing  the  hollow  sound  the  entire  canal 
and  tear  sac  may  be  flushed  out  with  the  medicated  solu- 
tion. The  introduction  of  the  sound  should  always  be 
followed  by  an  irrigation  of  this  kind. 

4.  Extirpation  of  the  tear  sac  in  cases  of  imper- 
meable stricture  that  lead  to  the  accumulations  of  secre- 
tions in  the  sac  and  irritation  of  the  eye  with  danger  of 
purulent  keratitis  is  an  excellent  operation,  which,  as  a 
rule,  is  followed  by  very  good  results  and  leaves  a  very 
slight  scar.  It  is  much  to  be  preferred  to  obliteration  of 
the  sac  with  caustics,  which  was  formerly  in  vogue.  An 
incision  having  been  made  from  the  front,  after  Petit,  or 
from  the  side  by  splitting  both  canaliculi,  the  slits  were 
deepened  until  they  extended  into  the  sac.  It  is  also 
preferable  to  curettage  and  cauterization  by  means  of  Pet- 
it's  incision.  This  ancient  operation  was  again  recom- 
mended, especially  by  Berlin,  and  has  gradually  won  gen- 
eral acceptance. 

As  a  preparatory  measure  it  is  well,  if  possible,  to  flush 
out  the  sac  with  protargol  for  several  days,  so  as  to  cleanse 
it  at  least  partially.  The  operation,  unless  dense  adhesions 
of  the  sac  from  former  inflammatory  conditions  and  forcibe 
sounding  are  suspected,  may  be  performed  under  local 
anesthesia  with  eucain-cocain-adrenalin.     If  the  adrenalin 


358  OPERATIONS  ON  THE  EYE. 

is  added,  the  hemorrhage,  which  is  so  troublesome  in  this 
operation,  is  usually  quite  inconsiderable,  and  the  oper- 
ation, therefore,  much  less  difficult.  In  general  anesthesia, 
especially  with  ether,  the  hemorrhage  may  be  very  severe 
and  very  troublesome,  particularly  in  obese  persons. 
From  time  to  time  the  wound  must  be  sponged  with 
cocain-adrenalin  and  the  operation  interrupted  to  wait  for 
the  drug  to  act.  In  rather  anemic  and  emaciated  indi- 
viduals the  operation  may  be  quite  a  simple  one,  particu- 
larly if  the  sac  is  somewhat  dilated  and  the  walls  are  thick. 
Under  local  anesthesia  the  above-mentioned  solution  is 
injected  not  only  into  the  sac  itself,  but  also  subcutaneously, 
and  to  some  depth  into  the  tissues  surrounding  the  sac. 
Ten  minutes  should  be  allowed  to  elapse  before  beginning 
the  operation,  when  it  may  be  performed,  if  not  quite 
painlessly,  at  least  without  giving  the  patient  very  much 
discomfort. 

As  the  wound  is  very  deep,  it  is  indispensable  to  have  a 
good  light;  if  necessary  an  electric  light  reflected  from  a 
head  mirror.  For  the  same  reason  it  is  better  to  make 
the  skin  wound  large — that  is,  from  2  to  3  mm.  in  length 
— so  as  to  gain  free  access  to  the  operative  field.  As  the 
scar  is  usually  invisible,  1  cm.,  more  or  less,  is  of  no  im- 
portance. The  incision  is  carried  in  a  curved  direction 
around  the  inner  canthus  over  the  nasal  extremity  of  the 
palpebral  ligament,  so  that  ^  of  it  lies  above  and  the  other 
§  of  it  below  the  said  ligament.  It  is  best  to  carry  the 
initial  incision  as  far  as  the  palpebral  ligament,  which  is 
divided  near  its  insertion  in  the  bone.  The  nasal  wall  of 
the  sac  is  then  dissected  away  along  the  ligament,  after 
which  the  upper  dome  is  separated  with  the  scissors  and 
blunt  dissector.  The  temporal  wall  of  the  sac  is  then 
exposed,  the  operator  taking  great  care  not  to  go  too  near 
the  globe  nor  to  injure  the  internal  rectus.  I  once  saw  an 
operation  for  extirpation  of  the  lacrimal  sac  (not  performed 
by  me),  in  which  the  muscle  was  probably  partly  excised, 
complete  loss  of  function  of  the  internal  rectus,  and, 
although  I  made  two  attempts,  I  was  unable  to  correct  the 


OPERATIONS  ON  THE  LACRIMAL   OMGANS     359 

condition.  It  is  therefore  important  to  keep  the  wound  in 
constant  view  either  by  means  of  hooks  or  Midler's  re- 
tractor (Fig.  141)  and  Axenfeld's,  which  holds  the  wound 
apart  from  below  upward  also.  In  addition  it  is  indis- 
pensable to  keep  the  operative  field  clean  by  constant 
sponging  ;  in  some  cast'.-  it  may  be  necessary  to  ligate  the 
artery.  After  the  sac  has  thus  been  exposed  (Plate  30), 
it  is  fixed  with  a  heavy  pair  of  forceps,  freed  on  its  poste- 
rior surface,  and  finally  divided  at  its  lower  extremity 
where  it  merges  into  the  lacrimonasal  duct. 

When  it  is  impossible  to  dissect  out  the  sac  in  this  way 
as  a  whole,  the  operation  must  be  completed  with  a  sharp 
knife,  as  no  part  of  the  mucous  membrane  must  be  left 
behind.  In  doing  so  the  upper  portion  of  the  lacrimo- 
nasal duct  may  also  be  curetted  away,  but  the  curet  should 
not  be  carried  too  far  down,  as  the  blood  may  flow  into  the 
nose,  pharynx,  and  larynx. 

After  the  wound  cavity  has  been  well  flushed  out  with 
1  :  1000  bichlorid  solution  and  wiped  out  with  sponges,  it 
may  be  dusted  with  a  little  iodoform  powder;  although 
this  is  not  necessary.  The  skin  wound  is  then  closed  with 
a  few  deep  and  several  superficial  sutures,  iodoform  gauze 
is  applied,  and  the  eye  bandaged  with  gentle  pressure. 
Convalescence  is  usually  remarkably  good,  and  in  from 
six  to  seven  days  the  sutures  can  be  removed  and  the 
wound  can  be  painted  with  iodoform  collodium.  Many 
operators  prefer  to  split  the  sac  before  turning  it  out,  and 
then  to  dissect  it  out.  It  is  possible  that  this  procedure 
may  render  it  easier  to  find  the  sac,  which  is  often  diffi- 
cult in  the  deep  bloody  wound.  By  taking  one's  bearings 
by  the  palpebral  ligament,  and,  if  necessary,  by  filling  the 
sac  with  fluid  during  the  operation  through  one  of  the 
eanaliculi,  it  is  hardly  possible  to  miss  it. 

The  filling  the  sac  with  paraffin  is  a  good  operation 
when  it  is  successful ;  but  its  performance,  as  I  have  sat- 
isfied myself,  is  not  very  easy.  In  suitable  cases  it  may 
be  effected  by  means  of  von  Pflugk's  syringe  and  heating- 
iron,  which  can  be  obtained  from  Windier,  in  Berlin. 


LITERATURE. 


A.  f.  O.  signifies  v.  Gräfes  Archiv  für  Ophthalmologie,  z.  Z.,  edited 
by  Leber,  Sattler  und  Snellen.  A.  f.  A.,  Archiv  für  Augenheilkunde 
von  Knapp  und  Schweigger.  Monbl.  f.  A.,  Klinische  Monatsblätter  für 
Augenheilkunde  von  v.  Zehender,  1900,  edited  by  Axenfeld  und  Uhthoff. 


1.  Snellen,  Handbuch  v.  Gräfe  und   Saemisch.  2.   Aufl.  4.   Bd.  Kap. 

IL  1902. 

2.  Czermak,  v.  Michels  Jahresbericht  fürOph  thai,  für  1901.  p.  314. 

3.  Laqueur,  Leber  Chloroformtod  durch  Herzlähmung.  Dtsche.  med. 

Wochenschr.  1902.  No.  7. 

4.  Haab,1  Bei  welchen  Operationen  soll  Cocain  angewendet  werden? 

Corresp.  Bl.  f.  Schweizer  Aerzte.  1891.  p.  97. 

5.  Knapp   H.,    Betrachtungen  über   Staaroperation   mit  Zugrundele- 

gung einer  grösseren  Statistik  neuer  Fälle.  XII.  int.  Kongress 
M-.skau.  Bericht  d.  Sekt.  XI  p.  45.  1898. 

6.  Arlt,  Handbuch  von  Gräfe  und  Saemisch.  1.  Aufl.  Bd.  3.  Cap.  IL 

Operationslehre.  1874. 

7.  I lorner,  Die  Staarextraktion  der  Ophthalm.  Klinik  in  Zürich  von 

C.  v.  Muralt.  Diss.  1881. 

8.  (Haab),  Mitteilungen  über  400  Staaroperationen,  ausgeführt  von 

Prof.  O.  Haab  an  Kranken  der  Zürcher  Universitätsund  seiner 
Privat-Augenklinik,  von  Th.  Arnold,  Arch.  f.  A.  25.  Bd.  1892. 
p.  4L 

,  Leber  die  Wundbehandlung  am  Auge.  Corresp.  Bl.  f.  Schweiz. 

Aerzte.  1893.  p.  660. 

9.  Schmidt-Rimpler,  Lieber  Cornea-Impfungen  mit  blenn.  Tränensack- 

sekret. Berl.  klin.  Woehensch.  1876. 

10.  Sattler,    Bericht    der    Ophthal.    Gesellsch.    Heidelberg   1883    und 

1885  und  7.  inter.  Kongress  in  Heidelberg.  1888. 

11.  AVeeks,  Bakteriologische  L'ntersuchungen  über  die  in  der  Augen- 

heilk.  gebräuchlichen   Antiseptika.     A.  f.  A.  19.  1889.  p.  107. 

12.  (ravet,  Recherches  experimentales  sur  Fantisepsie  et  l'asepsie  ocu- 

laires.  Arch  d'Opht.  VII.  1887. 

13.  Hildebrandt,  Experimentelle  Lntersuehungen  über  Antisepsis  etc. 

Beitr.  z.  Augenheilk.  von  Deutschmann.  1.  Bd.  1893. 

14.  Bernheim,   Lieber   die    Antisepsis   des    Bindehautsackes    und    die 

bakterienfeindliche  Eigenschaft  der  Tränen.  Beitr.  z.  Augen- 
heilk. von  Deutschmann.  1.  Bd.  1893. 

1  Haab,  Augen  <  >i>erationslehre. 

361 


362  LITERATURE. 

15.  Marthen,    Experimentelle    Untersuchungen    über    Antisepsis   bei 

Augenoperationen    und   die    Bakteriologie   des  Konjunktival- 
sackes.  Ebenda.  2.  Bd.  1893. 

16.  Bach,  lieber  den  Keimgehalt  des  Bindehautsackes,  etc.     A.  f.  O. 

40.  Bd.  3.  1894. 

17.  Helleberg,  Zur  Frage  der  bakterientötenden  Wirkung  der  Tränen. 

Hygiea  1900  und  Mitteilungen  aus  der  Augenklinik  zu  Stock- 
hohn. 3.  Heft.  1901. 

18.  Franke,    Untersuchungen    über   die    Desinfektion   des    Bindehaut- 

sackes etc.  A.  f.  O.  39.  3.  1893. 

—  — ,  Weitere  Untersuchungen  über  Asepsis   und  Antisepsis   in  der 

Augenchirurgie.  A.  f.  O.  43.  1.  1897. 

19.  Bach,  Experimentelle  Untersuchungen  über  die    Infektionsgefahr 

penetrierender  Bulbusverletzungen  etc.  A.  f.  A.  30.  1895. 

—  — ,  Antisepsis  oder  Asepsis  bei  Bulbusoperationen?  A.  f.  A.  Bd. 

33.  1896. 

20.  Dalen,  Experimentelle  Untersuchungen  über  die  Desinfektion  des 

Bindehautsackes.    Mitteilungen  aus  der  Augenklinik  zu  Stock- 
holm von  Widmark.  1.  Heft.  1898. 

21.  Haab,  Bemerkungen  zur   Staaroperation.   Beiträge  z.  Augenheilk. 

v.  Deutschmann.  1.  Bd.  p.  252.  1891. 

22.  v.  Pflugk,  Ueber  die  Vorbereitung  des  Lidrandes  und  der  Cilien 

für  Bulbusoperationen.  A.  f.  A.  45.  Bd.  p.  176.  1902. 

23.  Eversbusch,    Ueber    die    Anwendung    der    Antimycotica    in    der 

Augenheilkunde.  Zentralbl.  f.  A.  1890.  p.  354. 

24.  Sidler-Huguenin,    Ueber    die    Einwirkung    der    Sterilisationsver- 

fahren  auf    Kokainlösungen   und   über    die    beste    Methode 
Cocain-  und  Atropinlösungen  steril  aufzubewahren.  Korresp. 
■  Bl.  f.  Schweiz.  Aerzte.  1900. 

25.  Brunner,   Konrad,   Erfahrungen  und  Studien  über  Wundinfektion 

und  Wundbehandlung.  Frauenfeld.  1899. 

26.  Schirmer  O.,  Ueber  benigne  postoperative  Cvclitis  auf  infektiöser 

Basis.  IX.  Int.  Ophthal.  Kongress  in  Utrecht  1899.  Bericht  p. 
402. 

27.  Gräfe,  Alf. ,  Fortgesetzter  Bericht  über  die  mittelst  antisept.  Wund- 

behandlung erzielten  Erfolge  der  Staaroperation.  A.  f.  O.  35. 
3.  1889. 

28.  Bunge,  Ueber  schädliche  Wirkungen   des  Cocains  auf  die  Horn- 

haut. Monbl.  f.  Augenheilk.  1885.  p.  402. 

29.  Haab,  Ueber  intraoculare  Desinfection.    IX.    Congres  int.    Utrecht 

1899.     Bericht  p.  425. 

30.  Sidler-Huguenin,   Herstellungsweise    der   Jodoformstäbchen    und 

-Plättchen  für  die  intraokuläre  Desinfektion.     Zeitschr.  f.  A. 
Bd.  X.  p.  108.     1903. 

31.  Haab,  Weitere  Mitteilungen  über  Panophthalmie-Bazillen.     Fort- 

schritte der  Medizin.     Okt.     1891. 

32.  Silberschmidt  und   Baenziger,  Zur  Aetiologie  der  Panophthalmie 

nach     Hackensplitterverletzungen.     Bericht  der   Ophth.   Ge- 
sellsch.     Heidelberg.     1902. 

33.  Römer,  Zur  Frage  der  Jodoformwirkung  bei  intraocularen  Infek 


LITERATURE.  363 

tionen.  Bericht  der  Ophthal.  Gesellsch.  Heidelberg.  1901. 
p.  209. 

34.  Foerster,  R..  Künstliche  Keifung  des  Staares.     Bericht  der  Ophthal. 

Gesellseh.     Heidelberg.     1881. 

35.  Fuchs,  E.,  Ueber  Eiythropsie.     A.  f.  O.  Bd.  42.     4.     207.     1896. 

36.  Pagenstecher  Ad.  H.,  Ueber  Staaroperation  mit  besond.     Berück- 

sichtigung der  Xachstaaroperation.  Ztschr.  f.  A.  Bd.  X.,  p. 
206.     1903. 

37.  v.  Gräfe,  Nachträgliche  Bemerkungen  über  die  modifizierte  Linear- 

extraktion.    A.  f.  O.     12  Bd.  1.  p.    161.     1866. 

38.  Czermak,  Die  Augenärztlichen  Operationen  p.  596.     1896. 

39.  Magnus,  Zur  histor.  Kenntnis  der  Vorderkammer-Auswaschungen. 

A.  f.  O.     Bd.  34.     2.  p.  167.     1888. 

40.  M'Keown,  A  treatise  on  unripe  cataract.     London,  1898. 

41.  Lippincott,  J.  A.,  Routine  Syringing  Out  of  Cortical  Matters  in  Cat- 

aract Extraction,  as  Illustrated  by  One  Hundred  Cases. 
Transact.  Americ.  Ophth.  Soc.     1891*. 

42.  Röthlisberger,  Ueber  die  Ausspühlungen  der  vorderen  Augenkam- 

mer  bei  der  Staarextraktion  an  der  Basler  ophth.  Klinik. 
Diss.     1893. 

43.  Erb,  Ein  neues  aseptisches  Instrument  zur  Ausspühlung  der  vord. 

Kammer  bei  der  Staarextraktion.  Ztschr.  f.  A.  Bd.  8.  p. 
303.     1902. 

44.  Elliot,  R.  H.,  M'Keown's  Method  of  Irrigation  in  Cataract  Opera- 

tion.    The  Indian  Medical  Gazette,  Vol.  38.     1903. 

45.  Pope,  T.  H.,  On  Cataract  and  its  Extraction  in  the  Government 

Ophthalmic  Hospital,  Madras.  The  Indian  Medical  Gazette. 
Vol.  36.     1901. 

46.  Pagenstecher  H.,  Ueber  Staarextraktionen  mit  und  ohne  Entfer- 

nung der  Kapsel.     A.  f.  O.     34.     2.  p.  144.     1888. 

47.  Knapp,  H. ,  Operations  Usually  Performed  in  Eye  Surgery.     System 

of  Diseases  of  the  Eye,  by  Xorris  and  Oliver.    Vol.  III.    1898. 

48.  Taylor,  L.  H.,  A  Case  of  Acute  Panophthalmitis  following  Discis- 

sion of  the  Capsule.     Trans.  American  Ophth.  Soc.     1903. 

49.  Kuhnt,  L'eber  Xachstaaroperation.     Ztschr.  f.  A.     1.   Bd.  p.  151. 

1899. 

50.  Axenfeld,  Die  Technik  der  optischen  Iridektomie.     Verhandlung. 

der  Ophthalmolog.  Gesellsch.  in  Heidelberg  1903,  Monatsbl. 
f.  A.  903.     11.     253. 

51.  Treacher  Collins,  On  the  Operative  Treatment  of  Glaucoma.   Ophth. 

Hosp.  Rep.  XIII.  p,  166.     1891. 

52.  Priestley  Smith,  Glaucoma :  Pathogenesis,  Symptoms,  Course,  and 

Treatment.  System  of  Diseases  of  the  Eve,  edited  bv  Xorris 
and  Oliver,  vol.  III.  p.  629.     1898. 

53.  Weber  Ad.,  Die  Ursache  des  Glaukoms.     A.  f.  O.  23.     1.  p.  1.  1877. 

54.  Deutschmann,  Weitere  Mitteilungen  über  mein  Heilverfahren  bei 

Xetzhautablösung  etc.  Beitr.  z.  Augenhlk.  v.  Deutschmann. 
40.  Heft.  1899  und  Verhandl.  der  Ophthal.  Gesellsch.  in 
Heidelberg  1903. 

55.  Müller  L.,  Ein  neues  Operationsverfahren  zur  Heilung  der  Xetz- 


364  LITERATURE. 

hautabhebung.      Münchener.      Mediz.     Wochenschr.      1903. 
p.  977. 

56.  Knapp  H.,  Ueber  einige  neue  namentl.  plastische  Konjunktival- 

operationen.     A.  f.  O.     14.  Bd.     1.  p.  267.     1868. 

57.  McReynolds,  The  Nature  and  Treatment  of  Pterygia.    Jour.  Americ. 

Med.  Assoc.  Aug.  9,  1902  et  Annals  of  O.     1902,  p.  754. 

58.  Kulmt,  Ueber  die  Verwendbarkeit  der  Bindehaut  in  der  praktischen 

und  operativen  Augenheilkunde.     Wiesbaden  1898. 

59.  Cofler,  II  tatuaggio  della  Cornea  con  speciale  riguardo  a  quello 

variopinto  ed  a  quello  delle   palpebre.     Annali  di   Ottalm. 
1902  p.  169. 

60.  de  Wecker,  Die  Tättowirung  als  Ersatz  der  Prothese.     Monatbl.  f. 

A.  1902.     I.  p.  374. 

61.  Nieden,  Ueber  eine  neue  Tätowirmethode  u.  die  Benutzung  eines 

neuen    Tätowirmaterials.      Ber.   d.    Ophthal.    Gesellsch.    in 
9  Heidelb.  1901.  p.  249. 

62.  Weidmann,  Ueber  die  Verletzungen  des  Auges  durch  Fremdkörper, 

Diss.  Zürich.  1888. 

63.  Hirschberg,  Die  Magnetoperation  in  der  Augenheilkunde,  2.  Aufl. 

1899. 

64.  Pooley,  Der  Nachweis  und  die  Lokalisation  von  Stahl-  und  Eisen- 

partikeln im  Auge  durch  die  Indikationen  der  Magnetnadel. 
A.  f.  A.     10.  Bd.  p.  9  u  p.  315.     1881. 

65.  Asmus,  Das  Sideroscop.     A.  f.  O.     40.     Bd.  p.  280.     1894.     u.  A. 

f.  A.     29.     Bd.     1894. 

06. ,  Meine  Erfahrungen  mit  dem  Sideroskop  seit  Einführung  der 

elektrischen  Strassenbahn  in  Düsseldorf.     Monatbl.  f.  A.  1901 
p.  423. 

67.  Knies,  Extraktion   eines  nicht  sichtbaren  Fremdkörpers  aus  dem 

Auge  mit  Hülfe   eines  Elektromagneten.     Monbl.  f.  A.  Bd. 
19.  p.  30.     1881. 

68.  Haab,  Die  Verwendung  sehr  starker  Magnete  zur  Entfernung  von 

Eisensplittern  aus  dem  Auge.     Bericht  der  22.  Versamml.    d. 
Ophthal.  Gesellsch.  in  Heidelb.  1892,  p.  163. 

69.  Grüning,  Wounds    and    Injuries  of  the    Eyeball,  etc.  System    of 

Diseases  of  the  Eye  ed.  b.  Norris  and  Oliver,  vol.  Ill,  p.  705. 

70.  Lang,  W.,  A   Note  on  the  Use  of  Haab's  Magnet.  O.  Hosp.  Rep. 

Vol.  XV.,  p.  296,  1903. 

71.  Haab,    Ueber     die   Anwendung  des    grossen   Magneten   bei  der 

Ausziehung  von  Eisensplittern  aus  dem  Auge.     Ztschr.  f.  A. 
VIII,  p.  587.  1902. 

72.  Knapp,  H,  Die  Entfernung  von  Fremdkörpern    aus   dem  Innern 

des  Auges.  A.  f.  A.  8.  p.  71,  1879. 

73.  Gayet,  De  la  conduite  ä  tenir  dans  les  cas  de  penetration  dans  la 

chambre  anterieure  de   l'oeil  de  certains  corps  etrangers  (Sta- 
cheln von  Kastanienschalen).    Arch.  d'Ophtal.  19.  p.  454.  1899. 

74.  Javal,  Manuel  du  Strabisme.     Paris,  1896. 

75.  Priestley  Smith,  On  the  Etiology  and  Educative  Treatment  of  Con- 

vergent   Strabismus.     Bowman    lecture.     Trans,   o.  soc.  unit, 
kingd.  Vol.  18  p.  17.  1898. 


LITERATURE.  365 

76.  Worth   Claude,   Squint :    Its   Causes,   Pathology,  and   Treatment. 

London,  1903. 

77.  Arlt,   Handbuch  der  gesamten    Augenheilkunde  von   Gräfe   und 

Saemisch  Bd.  III.  p.  398.  1874. 

78.  Snellen,  Klin.  Monbl.  f.  A.  1870,  p.  26. 

79.  Knapp,  H.,  Erzielung  grösserer  Wirkung  bei  der  Schiel-operation. 

Monbl.  f.  A.  1865,  p.  346. 

80.  Fröhlich,  C,   Ueber  die  Muskelvorlagerung  als  Schiel-operation. 

Monbl.  f.  A.  1900,  p.  369. 

81.  de  Wecker,  De  1'  avancement  musculaire  au  rnoyen  du  double  fil. 

Ann.  d'Ocul.  Bd.  70.  1873.  p.  225. 

82.  Landolt,  La  technique  de  Pavancement  musculaire.    Arch.  d'Opht. 

Bd.  21.  p.  369.  1901. 

83.  Prince  A.  EL,    The  Pulley  Method  of  Advancing  the  Rectus  with 

Indications  for  its  Employment.  Ophthalmic  Review,  1887, 
and  St.  Louis  Med.  and  Surg.  Jour.  1888. 

84.  Verhoeff  F.  H.,  A  Secure  Stitch  for  Advancement  Operations.    The 

Ophthal.  Record,  1901. 

85.  de  Wecker,  Sur  Population  du  strabisnie  au  moyen  de  Pavancement 

capsulaire.  Ann  d'ocul.  T.  90  p.  188.  1883  u.  Arch.  d'Opht. 
T.  13.  p.  1.  1893 

86.  Todd,  A  Secure  Advancement  Operation  Performed  with  the  Aid  of 

a  New  Tendon  Tucker.  The  Ophth.  Record,  Vol.  XL,  p.  73, 
1902. 

87.  Brand,  Ueber  Muskel vorlagerung.  A.  f.  A.  1902. 

88.  Schweigger,   Die  Erfolge  der  Schieloperation.  A.  f.  A.  29.  p.  165. 

1894 

89.  Koster,   Muskelverkürzung.    Versamml.     der    Niederl.    Ophthal. 

Gesellsch.  Dec.  1901  und  van  der  Hoeve,  Beiträge  zur  Lehre 
vom  Schielen.  A.  f.  A.  46.  p.  204.    1902. 

90.  Müller,  L.,  Die  Muskelausschneidung  als  Schieloperation.  Monbl. 

f.  A.  1893.  p.  118. 

91.  Verhoeff  F.  H.,   Eine  graduelle  plastische  Tenotomie.    Monbl.  f. 

A.  Bd.  41.  1903. 

92.  Schweigger,  Ueber  Resektion  der  Sehnerven.  A.  f.  A.  15.  p.  50. 

1885. 

93.  de  Wecker,  Le  traitement  de  Pophthalmie  sympathique.  Annales 

d'Ocul.  _  T.  104.  p.  209.  1890. 

94.  Knapp,  Exstirpation  einer  Schnervengeschwulst  mit  Erhaltung  des 

Augapfels,  Monatsbl.  f.  A.  1874.  p.  439.,  sowie  Operationslehre 
in  Xorris  und  Oliver  (1.  cit). 

95.  Lagrange,  De   la  conservation  du  globe  de  l'oeil  dans  l'extirpation 

des  tumeurs  du  nerf  optique.  Congres  francais  de  Chirurgie, 
Paris  1892. 

96.  Krönlein,  Zur   Pathologie   und  operativen  Behandlung  der  Der- 

moidcysten der  Orbita.  1.  Das  Zwerchsackdermoid  der  Orbita. 
2.  Die  osteoplastische  Resektion  der  äusseren  Orbitalwand  als 
Vorakt  für  die  Exstirpation  von  tiefsitzenden  latenten  Orbital- 
tumoren, insbesondere  von  Orbitalclermoiden.  Beitr.  z.  klin. 
Chirurgie  herausg.  von  v.  Bruns  Bd.  4  p.  149.  1889. 


366  LITERATURE. 

97.  Schuchardt,   Krönleins   Operation,   Osteom  des  Orbital    daches. 

Berlin  Hin.  Woch.  1897  S.  594. 

98.  Torek.  Krönleins  Operation,  Tumor  der  Tränendrüse,  New  Yorker 

Med.  Monatsschrift  1902.  p.  32. 

99.  Domela — Nieuwenhuis,    Ueber    die   retrobulbäre   Chirurgie    der 

Orbita.  Beitr.  z.  klin.  Chirurgie  von  v.  Bruns  Bd.  27.  1900. 

100.  Parinaud  et    Roche,   Angio-fibrome  de    l'orbite,  »modification  au 

procede  de  Krönlein.  Ann.  d'Ocul.  Bd.  126  p.  241.  1901. 

101.  Rollet,  Exophthalmie  guerie  par  Orbitotomie  malaire.    Ann.  d'Ocul. 

Bd.  126.  p.  370.  1901. 

102.  Cahan,  (Resektion  des  Orbitaldaches)  Zentralbl.  f.  Chirurg.  1897. 

S.  737. 

103.  Franke,  Eine  neue  Methode  der  osteoplastischen  Freilegung  der 

Orbita.     Dtsche.  Ztschrift  f.  Chirurg.  Bd.  59.  1901% 

104.  Gussenbauer,  (Resektion  der  äusseren  Orbitalwand).  Wiener  klin. 

Wochensch.  1895. 

105.  Krönlein,  Die  v.  Langenbeck'sche  Klinik  und  Poliklinik  zu  Berlin 

während  der  Zeit  vom  1.  Mai  1875  bis  31.  Juli  1876.  Berlin 
1877.  S.  72  u.  73.  (Fälle  34  u.  35  der  Tabelle.) 

106.  Küster,  Die  Deckung  der  Augenhöhle  nach  Ausräumung  derselben. 

Centralb.  f.  Chirurg.  1890.  und  Peren  (gleicher  Titel)  Inaug. 
Diss.  Marburg  1891. 

107.  Pagenstecher,  FL,  Ein  neues  Operations  verfahren  zur  Heilung  der 

Ptosis.  Transact,  of  the  int.  med.  Congr.  London,  p.  108.  1801. 

108.  de  Wecker,  Une  nouvelle  operation  du  ptosis.     Ann.  d'ocul.  Bd. 

88.  p.  29.  1882. 

109.  Dransart,  Ouerison  du  ptosis  par  des  procedes  operatoires  speciaux. 

Ann.  d'Ocul.  Bd.  88  p.  147.  1882. 

110.  Hess,  Eine  Operationsmethode  gegen  Ptosis.     A.  f.  A.  Bd.  28.  p. 

22.  1894. 

111.  Panas,  D'un  nouveau  procede  operatoire  applicable  au  ptosis  con- 

genital et  au  ptosis  paralytique.  Arch.  d'Ophtal.  Bd.  6.  p.  1. 
1887. 

112.  Motais,  La  methode  operatoire  du  ptosis  par  la  suppliance  du  M. 

droit  superieur.  Communication  ä  l'Acad.  de  Med.  Seance  du 
24.  Mars  1903. 

113.  Cannas,  N.,  Operazione  della  ptosis  median te  la  sutura  del  mus- 

culo elevatore  della  palpebra  al  muscolo  retto  superiore. 
Torins  S.  A. 

114.  Eversbusch,   Zur  Operation    der    congenita   len    Blepharoptosis. 

Monb.  f.  A.  1883  p.  100. 

115.  —  (Ptosisoperation)   Monb.   f.    A.    1893.     Bericht  über  die  Ver- 

samml.  i.  Heidelb.  p.  146. 

116.  Snellen,  (Ptosisoperation)  Monb.  f.   A.  1893.  Ber.  über  die  Ver- 

sammi.  i.  Heidelb.  p.  150.  u.  Trans,  of  the  Ophthal,  soc.  of  the 
unit.  Kingd.  Vol.  X  p.  208.  1889. 

117.  Wolff,  Hugo,  Die  Vorlagerung  des  Muse,  levator  palp.  sup.  mit 

Durchtrennung  der  Insertion.  Zwei  neue  Methoden  gegen 
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LITERATURE.  367 

118.  Lapersonne,  Sur  quelques  modifications  dans   les   operations  du 

ptosis.     Arch.  d'Opht.  Bd.  23.  p.  479.  1903. 

119.  Elschnig,  Ptosisope ration.     Wiener  Medic.  Wochenschrift    1903. 

No.  51. 

120.  Boucheron,  Operation  du  ptosis.     La  tarsectomie  aver  avancement 

du  muscle  rcleveur  de  la  paupiere.  Arch.  d'Opht.  Bd.  8.  p. 
229.  1888. 

121.  Gillet   de   Grandmont,  Xouvelle  Operation  du  ptosis  congenital. 

Recueil  d'  Opht.  1891.  p.  267  und  Ann.  d'Ocul.  Bd.  105.  p. 
237.  1891. 

122.  Gruening,  E.  C,  The  Value  of  Partial   Resection  of  the  Tarsal 

Cartilage  in  the  Operative  Treatment  of  Congenital  Ptosis. 
Trans.  Americ.  Ophth.  Soc.  1902.  p.  574. 

123.  Marple  W.  P.,  Case  of  Traumatic  Ptosis  of  the  Left  Eye  <  »perated 

upon,  with  Most  Satisfactory  Result,  According  to  the  Method 
of  Dr.  Gruening  or  Gillet  de  Grandmont.  The  Ophthal. 
Record.  Bd.  12.  p.  493.  1903. 

124.  Green,  J.,  Case    of  Readjustment  of  the   Levator  Muscle    of   the 

Upper  Lid.     Trans.  American  Ophthal.  Soc.  1871.  p.  134. 

125.  Spencer,  Watson,  On  the  Treatment  of  Trichiasis  and  Distichiasis 

by  a  Plastic  Operation.     Med.  Times  and  Gaz.  Vol.  49.  1874. 
—    On   a    new   Operation    for   Distichiasis,   with    a   Successful    Case. 
Ophth.  Hosp.  Rep.  VIL  1873. 

126.  Hotz,  Eine  neue  Operation  für  Entropium  und  Trichiasis.  A.  f.  A. 

9.  Bd.  p.  68.  1880  und  Eine  Entropiumoperation  am  unteren 
Augenlid,  besonders  bei  alten  Leuten,  Monbl.  f.  A.  18.  Jahr- 
gang, p.  49.  1800. 

127.  Anagnostakis,  (Entropium-Operation).     Annales  d'Ocul.  Bd.  38. 

p.  5.  1857. 

128.  Pagenstecher  H.,  Ueber  Vorlagerung  der  Levatorsehne.  Ein  neues 

Operationsverfahren  von  Prof.  Dr.  H.  Pagenstecher  für  Ektro- 
pium  u.  Trichiasis  des  Oberlids,  v.  O.  Scheffels.  A.  f.  O.  Bd. 
36.  4.  p.  265.  1890. 

129.  Streatfield,  On  Grooving  the  Fibrocartilage  of  the  Lid  in  Cases 

of  Entropium  and  Trichiasis.  Ophth.  Hosp.  Rep.  Vol.  1,  p. 
121.  1858. 

130.  Snellen,  Beiträge  zur  Behandlung  gewisser  Krankheiten  der  Aug- 

enlider von  van  Gils,  Inaug.  Diss,  und  11.  Jahresbericht  über 
die  Leistungen  des  Nederlandsch.  Gasthuis  voor  Ooglijders  in 
Utrecht.  1870. 

131.  Hotz,  Die   Reposition   des   Lidrandes   bei   Trichiasis  des   oberen 

Lides.  Monatsbl.  f.  A.  26.  Jahrgang  p.  98.  1888. 

132.  Panas,  P/une  modification  apportee  au  procede  dit  de  Transplanta- 

tion du  sol.  ciliare.  Arch.  d'Ophtal.  Bd,  IL  1882  und  Traite 
des  maladies  des  yeux  2.  Bd.  p.  152.  1894. 

133.  Pfalz,  Leber  ein  Operationsverfahren  gegen  Entropium  und  Trich- 

iasis. A.  f.  O.  Bd.  33.  3.  p.  165.  1887. 

134.  v.  Arlt,  Operationslehre.  1.  cit.  Xr.  77. 

135.  Kuhnt.  Ektropiumoperatlon.  Beiträge  zur  operativen  Augenheil- 

kunde.    Jena  1883. 


368  LITERATURE. 

136.  v.  Siklösy,  Zur  Blepharoplastik.     Monatsbl.  f.  A.  Jahrg.  12  p.  228. 

1874. 

137.  Müller  L.,  Beitr.  z.  operat.     Augenheilkunde.    Monatsbl.  f.  A.  31. 

Bd.  p.  113.  1898. 

138.  Fricke,    Bildung  neuer  Augenlider    (Blepharoplastik)    nach  Zer- 

störung und  dadurch  hervorgebrachter  Auswärtswendung  der- 
selben. Hamburg  1829. 

139.  Dieffenbach,  Einige  Bemerkungen  aus  und    über  Paris.     Caspers 

Wochenschrift  1835. 

140.  Szymanowsky,    Handbuch    der     operativen    Chirurgie.      Braun- 

schweig 1870. 

141.  Thiersch  (Hauptpfropfung)   15   Kongress  der  deutschen  Gesell- 

schaft für  Chirurgie  1886  und  über  Hauptverpflanzung.  Zen- 
tral, f.  Chir.  No.  24  p.  17. 

142.  Kuhnt,  Ueber  den  Wert  der  Lidbildung    mittelst  Uebertragung 

stielloser  Hautteile.     Ztschr.  f.  A.  7  Bd.  p.  19.     1902. 

143.  Sachs,  Bemerkungen  zur  Lidplastik.     Ebenda  p.  44. 

144.  Axenfeld,  Plastische  Wiederherstellung  des  ganzen  Konjunktival- 

sackes  in  einem  Falle  von  Symblepharon  et  Ankyloblepharon 
cicatriceum  totale.     Monbl.  f.  A.     1900.  p.  845. 

145.  Hotz,  Case  of  Symblepharon  of  the  Lower  Lid  Relieved  by  Skin 

Grafting.  Chicago  Med.  Soc.  Nov.  1901.  The  Chicago  Med. 
Eec  order. 

146.  May  Ch.,  Wiederherstellung  des   Konjunktivalsackes  in  einem 

Falle  von  totalem  Symblepharon  mit  Hilfe  Thiersch'scher 
Hautläppchen.  Archives  of  Ophthal.  28.  Bd.  u.  A.  f.  A.  40. 
p.  358  (Uebersetzung)  1900. 

147.  Landström,  Ueber  Operation  von  Symblepharon  nach  May,  Mit- 

teilungen aus  der  Augenklinik  des  Carol.  Med.  Chir.  Instit.  zu 
Stockholm,  herausg.  v.  Widmark.  4.  Heft,  1902. 

148.  Eversbusch,  Ueber  die  Verwendung  von  Epidermistransplanta- 

tionen  bei  den  plastischen  Operationen  an  den  Lidern  und  an 
der  Konjunktiva,  Münch.  Med.  Wochenschr.  1887.  No.  1.  u  2. 

149.  Landolt,  Nouveau  procede  de  blepharoplastie  und  Un  nouveau 

cas  de  blepharoplastie.  Arch.  d'Opht.  1.  Bd.  p.  9  et  p.  111. 
1881. 

150. De  quelques  operations  pratiquees  sur  les  paupieres.  Ebenna. 

5  Bd.  p.  489.     1885. 

151.  Knapp,  Demonstration  of  a  Roller-forceps  Constructed  According 

to  the  Mangle  Principle  for  Pressing  Out  Trachoma  Granula- 
tions, with  Remarks.  Trans.  Americ.  Ophth.  Soc.  1891.  p.  148 
und  A.  f.  A.     25  Bd.     p.  177.     1892. 

152.  Berlin,  Ueber  Exstirpation  des  Tränensackes.     Sitz.-Bericht  der 

Ophthal.  Gesellsch.  in  Heidelberg.     1868. 


NDEX 


Ablation  after  Arlt  for  pterygium, 

208 
Abscess  of  orbit,  279 
Accidents  and  mistakes  in   opera- 
tion for  cataract,  154 
interfering  with  healing  of  wound 
after  operations  for  cataract, 
163 
Adrenalin  anesthesia,  31 
cocain  for  hemorrhage,  33 
for  hemorrhage,  32 
Advancement,  Brand's  method.  258 
capsular,  de   Wecker' s   method, 

256 
de  Wecker's  method,  250 
Knapp's  method,  249,  257 
Roster's  method,  259 
Landolt's  method,  252 
Mailer's  myectomy  for,  259 
Prince's  method,  253 
Schweiggers  method,  258 
Todd's  method,  258 
Yerhoeff 's  method,  254 
Weber's  method,  24'.' 
Worth's  method,  255 
Anagnostakis'  operation  for  entro- 
pion, 314 
Anesthesia,  25 
adrenalin,  31 
beta-eucain  and  adrenalin  chlo- 

rid,  32 
bromethyl,  27 
chloroform,  25 

mortality  due  to,  28 
cocain,  29 

in  enucleation,  30 
in  iridectomy,  31 
in  removal  of  lacrimal  sac,  30 
in  strabismus,  29 
24 


Anesthesia,  collapse  during,  treat- 
ment of,  26 
enucleation  during,  26 
ether,  26,  28 

mortality  due  to,  28 
ethyl  bromid,  27 

chlorid,  28 
in  operation  for  cataract,  101 
local,  28 

Schleich's,  in  enucleation,  30 
Anesthetization,  25 
Angioma  of  orbit.  281 
Anterior  chamber,  blood  in,  punct- 
ure of  cornea  for,  206 
Operations  in.  215 
polar  cataract,  83 
synechia?,  separation  of,  215 
Antisepsis,  33 
Antvllus'   operation  for  ectropion, 

325 
Arlt's  method  of  nasal  tarsorrhaphy, 
323 
operation  for  pterygium,  208 
tenotomy  for  strabismus,  245 
Artificial  glass  eye-.  27s 

globe,  implantation  of,  in  Tenon's 
capsule,  278 
Asepsis,  33 

Asm  us'  sideroscope,  219 
Atropin  in  cataract,  danger  from, 
92 

Bacilli,  panophthalmia,  74 
Bandage,  mouth-,  during  operation, 

59,  60 
Bandaging,  45 
Beer's  flap  incision,  119 
Beta-eucain  and  adrenalin  chlorid 

anesthesia,  32 

369 


370 


INDEX. 


Black  cataract,  87 
Blepharophimosis,    operation    for, 
321 
canthoplastic,  321 
BJepharoplastic  operation,  328 
Dieflenbach's,  331 
Eversbusch's,  343 
Fricke' s,  329,  330 
Landolt's,  343 
Blood  in  anterior  chamber,  punct- 
ure of  cornea  for,  206 
Brand's   method   of    advancement, 

258 
Bromethyl  anesthesia,  27 

Canna's  modification   of    Motais' 

operation  for  ptosis,  302 
Canthoplastic  operations  for  bleph- 
arophimosis, 321 
Capillary  fistula  in  scar  of  wound 
after  operation  for  cataract, 
166 
Capsular    advancement     after     de 
Wecker,  256 
cataract,  82 
Capsule,  Tenon's,  implantation  of 

artificial  globe  in,  278 
Carcinomatous  growths  of  conjunc- 
tiva, 213 
Cataract,  accidents  and  mistakes  in 
operation  for,  154 
anterior  polar,  83 
atropin  in,  danger  from,  92 
black,  87 
capsular,  82 
complicated,  83 
first  stage  of,  86 
fourth  stage  of,  86 
juvenile,  81 

discission  for,  102 
after-treatment,  105 
preparations,  103 
operation  for,  102 
simple  linear  extraction  of,  106 
lamellar,  operation  for,  112 
maturity  of,  85 
diagnosis,  92 
methods  of  inducing,  90 
preliminary  iridectomy  for  in- 
ducing, 91 


Cataract,  Morgagnian,  86 
nuclear,  82 
operation  for,  81 

accidents     and     mistakes    in, 
154 
interfering  with  healing  of 
wounds  after,  163 
after-treatment,  1 62 
anesthesia  in,  101 
bodily  condition  of  patient  in, 

95 
capillary    fistula    in    scar    of 

wound  after,  166 
central  vision  in,  93 
function  in,  93 
general  condition  of  patient  in, 

95 
glaucoma  after,  166 
hemorrhage  from  choroid  in, 

161 
indications,  85 
iridectomy  preceding,  97 
iridocyclitis  after,  164 
iritis  after,  164 
maturity  of  cataract  in,  85 
method  of  applying  dressings, 

162 
peripheral  vision  in,  93 

projection-test    for    deter- 
mining, 93 
prolapse  of  vitreous  in,  157 
pupillary  reaction  in,  94 
purulent  infection  after,  165 
subconjunctival,  153 
suppurating  processes  in,  95 
over-ripeness  of,  83,  86 
partial  stationary,  operation  for, 

112 
percentages  of  losses  in,  35 
pyramidal,  83 
removal  of  lashes  and  eyebrows 

before  operation  for,  55 
second  stage  of,  86 
secondary  operation  for,  166 

de  Wecker's  method,  173 
senile,  81 
cortical,  82 
operation  for,  118 

couching  and  depression  in, 
174 


INDEX. 


371 


Cataract,  senile,  operation  for,  func- 
tional examination  in,  124 
preparatory  treatment,  124 
Wenzel's,  153 
with  capsule,  150 
with  iridectomy,  136 
without  iridectomy,  142 
soft,  operation  for,  108 
third  stage  of,  86 
traumatic,  operation  for,  108 
Cataracta  incipiens,  86 

nigra,  87 
( autery,  Paequelin's,  75 
( 'hair,  operating,  20 
Chloroform  anesthesia,  25 

mortality  due  to,  28 
Choroid,  hemorrhage  from,  in  ope- 
ration for  cataract,  161 
Cicatricial  ectropion,  327 

Thiersch's    method    of     skin- 
grafting  in,  332 
Cocain,  adrenalin,  for  hemorrhage, 
33 
anesthesia,  29 

in  enucleation,  30 
in  iridectomy,  31 
in  removal  of  lacrimal  sac,  30 
in  strabismus,  29 
in  operation  for  strabismus,  241 
Collapse  during   anesthesia,    treat- 
ment of,  26 
Conjunctiva,  carcinomatous  growths 
of,  213 
operations  on,  202,  345 
papilloma  of,  213 
polyps  of,  213 

sarcomatous  growths  of,  213 
utilization  of,  to  cover  defects  in 
cornea,  210 
Conjunctiva]  sac,  operations  in,  295 
Cornea,    defects  in,   utilization    of 
conjunctiva  to  cover,  210 
dermoids  of,  removal  of,  212 
ectatic  scars  of,   iridectomy  for, 

196 
foreign  bodies  in.  removal  of,  202 
operations  on,  202 
puncture  of,  206 

for  blood  in  anterior  chamber, 
206 


Cornea,  puncture  of,  for  deep  cor- 
neal ulcer-,  207 
staphyloma  of,  213 
staphyloma-formation  of,  iridec- 
tomy for,  196 
tattooing  of,  210 
ulcers  of,  deep,   paracentesis   of 
cornea  for,  207 
Cortical  cataract,  senile,  82 
Couching  and  depression  in  opera- 
tion for  senile  cataract,  174 

Da<  ry(  )stkx<  ..-is,  350 

de    Weckers   method  of   advance- 
ment, 250 
of  capsular  advancement,  256 
operation  for  secondary  cataract, 

173 
ptosis  operation,  297 

Dermoids   of  cornea,    removal    of, 
212 

Desmarres'    transplantation    opera- 
tion for  pterygium,  209 

Detachment  of  retina,  excision  of 
myrtle-shaped  piece  of  sclera 
for,  201 
puncture  of  sclera  for,  200 

Dieffenbach's  blepharoplastic  ope- 
ration, 331 

Dilation  of  nasal  duct  with  sounds, 
353 

Dimmer's  modification  of  Kuhnt's 
operation  for  ectropion,  327 

Disinfection,  68 

Dislocation  of  lens,  operation   for, 
175 

Dransart's  ptosis  operation,  297 

Dropping  bottle,  62.  64 
Sidler's,  64 

Duct,    lacrimonasal,    irrigation    of, 
350  _ 
nasal,   dilation  of,   with   sounds, 
353 

Ectropion,  cicatricial,  327 

Thiersch's    method    of    skin- 
grafting  in,  332 
operation  for,  323 
Antvllus',  325 
Kuhnt's,  325 


372 


INDEX. 


Ectropion,  operation  for,  Kuhnt's, 
Dimmer's  modification  of, 
327 
Müller' s  modification  of,  326 
Szymanowsky's,  324 
senile,  325 

Snellen's  suture  in,  324 
Electric  bell  for  patients  after  ope- 
ration, 20 
Electromagnet  for  removal  of  for- 
eign bodies,  216 
Elschnig's  ptosis  operation,  306 
Entropion,  operation  for,  308 
Anagnostakis',  314 
by  destroying  roots  of  cilia  by 

electrolysis,  309 
Flarer's,  320 
( raillard's  suture,  309 
Hotz's,  311 

with  tarsus  excision,  317 
Jasche-Arlt,  320 
Pagenstechers,  with  advance- 
ment of  levator  tendon,  314 
Panas',  318 
Pfalz's,  319 
Snellen's,  317 
Spencer  Watson's.  311 
Streatfield's,  316 
tarsi  »plastic,  316 
with   advancement   of  levator 
tendon,  314 
Snellen's  suture  for,  320 
Enucleation,  cocain  anesthesia  in, 
30 
during  anesthesia,  26 
of  eyeball,  265 

hemorrhage  in,  270 
implantation  of  artificial  globe 
in    Tenon's    capsule    after, 
278  _ 
indications  for,  272 
operations  substituted  for,  274 
suppuration  in,  274 
of  globe,  265 

Schleich's  anesthesia  in,  30 
Ervthropsia,  100 
Ether  anesthesia,  26,  28 
mortality  due  to,  28 
Ethyl  bromid  anesthesia,  27 
chlorid  anesthesia,  28 


Eversbusch's   blepharoplastic   ope- 
ration, 343 
ptosis  operation,  302 
Eversion,  simple,  of  lower  lacrimal 

punctum,  348 
Evisceration  of  eyeball,  275 
Excision  of  myrtle-shaped  piece  of 
sclera    for     retinal    detach- 
ment, 201 
Exenteration  of  eyeball,  275 

of  orbit,  291 

Extirpation  of  tear  sac,  357 

Eyeball,  enucleation  of,  265 

hemorrhage  in,  270 

indications  for,  272 

operations      substituted      for, 

274 
suppuration  in,  274 
evisceration  of,  275 
exenteration  of,  275 
outside  of,  operations  on,  239 
Eyelids,  operations  on,  295 

Fistula,    capillary,    in     scar    of 
wound    after    operation    for 
cataract,  166 
Flarer's    operation    for    entropion, 

320 
Eoeister's  method  of  inducing  ma- 
turity of  cataract,  90 
Foreign  bodies  in  cornea,  removal 
of,  202 
in  interior  of  eye  not  consisting 
of  iron,  removal  of,  237 
removal  of,  216 
Röntgen  ravs  in  diagnosis 
of,  229 
in  lens,  238 

in  sclera,  removal  of,  206 
in  vitreous  humor,  238 
Fricke's  blepharoplastic  operation, 
329,  330 

Gaillard's  suture  operation  for 
entropion,  309 

Ganglion,  sympathetic,  resection  of, 
for  glaucoma,  200 

Gillet  de  Grandmont's  ptosis  opera- 
tion, 307 

Glass  eyes,  278 


INDEX. 


373 


Glaucoma  after  operation  for  catar- 
act, 166 
iridectomy  for,  186 

retinal  hemorrhages  after,  195 
with    Grate's    cataract    knife, 

192 
with  keratome,  188 
with  scalpel  or  scarifier,  192 
malignant,  Weber's  operation  for, 

198,  199 
posterior  sclerotomy  for,l98 
resection  of  sympathetic  for,  200 
secondary,    iridectomy    for    pre- 
venting, 184 
Globe,  artificial,  implantation  of,  in 
Tenon's  capsule,  278 
enucleation  of,  265 
operations  on,  81 
Gräfe's  cataract    knife,  iridectomy 
for  glaucoma  with,  192 
linear  incision,  119 
tenotomy  for  strabismus,  242 
Grandmont's  ptosis  operation,  307 

Hemorrhage,    adrenalin    cocain 
for.   33 
adrenalin  for,  32 
from    choroid    in    operation    for 

cataract,  161 
retinal,     after     iridectomy     for 
glaucoma,  195 
Hess'  ptosis  operation,  298 
Hirschberg's  iron-searcher,  219 
Hospital  wards,  18 
Hotz's  lead  plate,  341 

operation  for  entropion,  311 
with  tarsus  excision,  317 
Humor,  vitreous,  foreign  body  in, 
238 

Illumination  of  operating  room, 

21 
Implantation  of  artificial  globe  in 

Tenon's  capsule.  278 
Instruments,  60,  76 
Iodoform,  54,  70 

pencil,    method    of    introducing 

into  anterior  chamber,  72 
Iridectomy,  179 

cocain  anesthesia  in,  31 


Iridectomy  for  ectatic  scars  of  cor- 
nea  and   staph  vloma-forma- 
tion,  196 
for  glaucoma,  186 

retinal  hemorrhages  after,  195 
with    Gräfe's    cataract    knife, 

192 
with  keratome,  188 
with  scalpel  or  scarifier,  192 
for   preventing   secondary    glau- 
coma, 184 
for  relief  of  increased  tension,  186 
for  sarcomatous  nodules  on    iris, 

196  ^ 
in  chronic  iritis,  to  prevent  re- 
lapses and  clear  up  vitreous, 
195 
optical,  180 
preceding  operation  for  cataract, 

97 
preliminary,   for    inducing    ma- 
turity of  cataract,  91 
senile   cataract   extraction   with, 
136 
without,  142 
Iridocyclitis  after  operation  for  cat- 
aract, It '»4 
Iris,   sarcomatous  nodules   on,  iri- 
dectomy for,  196 
Iritis  after  operation  for  cataract, 
164 
chronic,  iridectomy  in,  to  prevent 
relapses  and  clear  up  vitre- 
ous, 195 
Iron  in  eye,  magnet  operation  for, 
216 
magnetic  needles  for,  218 
removal  of,  216 
Iron-searcher  of  Hii-schberg,  219 
Irrigation  of  lacrimonasal  duct,  350 

Jasche-Arlt  operation  for  entro- 
pion, 320 
Juvenile  cataract,  81 
discission  for,  102 
after-treatment,  105 
preparations,  103 
operation  for,  102 
simple    linear    extraction    of, 
106 


874 


INDEX. 


Keratome,    iridectomy   for   glau- 
coma with,  188 
Knapp's  method   of  advancement, 
249,  257 
operation  for   broad  pterygium, 
209 
for  retrobulbar  tumors,  282 
Roster's   method  of  advancement, 

259 
Krönlein's  operation,  284 
indications  for,  291 
technic  of,  287 
Kuhnt's  ectropion  operation,  325 
Dimmer's    modification    of, 

327 
Müllers  modification  of,  326 

Lacrimal       fluid,       bactericidal 
quality  of,  41 
organs,  operations  on,  347 
punctum,  lower,  simple  eversion 

of,  348 
sac,  removal  of,  cocain  anesthesia 
in,  30 
Lacrimonasal   duct,    irrigation    of, 

350 
Lagrange's  operation  for  retrobul- 
bar tumors,  282 
Lamellar    cataract,   operation   for, 

112 
Landolt's     blepharoplastic    opera- 
tion, 343 
method  of  advancement,  252 
Lapersonne's  ptosis  operation,  305 
Lens,  dislocation  of,  operation  for, 
175 
foreign  bodies  in,  238 
removal  of,  in  high  myopia,  176 
Light  in  operating  room,  21,  22 

of  room  after  operation,  20 
Linear   extraction,    simple,    of  ju- 
venile cataract,  106 
of  soft  cataract,  108 
incision,  von  Gräfe' s,  119 
Literature,  361 

Magnet  operation  for  iron  in  eye, 

216 
Magnetic  needles  for  iron  in  eye, 

218 


Malignant  glaucoma,  Weber's  ope- 
ration for,  198,  199 

Mask,  mouth-,  during  operation, 
59,  60 

Maturity  of  cataract,  85 
diagnosis  of,  92 
methods  of  inducing,  90 
preliminary  iridectomy  for  in- 
ducing, 91 

May's  glass  plate,  341 

McReynold's  modification  of  Des 
marre's  operation  for  ptery- 
gium, 209 

Morgagnian  cataract,  86 

Motais'  ptosis  operation,  300 

Gannas'  modification  of,  302 

Mouth-bandage  during  operation, 
59,  60 

Mouth-mask  during  operation,  59, 
60 

Muller's   modification   of  Kuhnt's 

operation  for  ectropion,  326 

myectomy   for    advancement   in 

strabismus,  259 
operation  for  retinal  detachment, 
201 

Muscle,  squinting,  antagonist  of, 
operations  on,  249 

Muscles,  ocular,  operations  on,  239 

Myectomy,  Muller's,  for  advance- 
ment in  strabismus,  259 

Myopia,  high,  removal  of  lens  in, 
176 

Nasal,     duct,    dilation     of,    with 
sounds,  353 
tarsorrhaphy,  323 
Nerve,  optic,  resection  of,  274 
Neurectomia  opticociliaris,  274 
Nodules,  sarcomatous,  on  iris,   iri- 
dectomy for,  1 96 
Nuclear  cataract,  82 

Ocular    muscles,   operations    on, 

239 
Operating  chair,  20 
rooms,  18 

arrangement  of,  21 
illumination  of,  21 
table,  20,  24 


INDEX. 


375 


Operation,  care  after,  42 

electric  bell  for  patient  after,  20 
light  of  room  after,  20 
mouth-bandage  during,  59,  60 
mouth-mask  during,  59,  60 
pollution  after,  avoidance  of,  59 
salivary  infection  during,  59 
ventilation  of  room  after,  20 

Operations,  81 

Optic  nerve,  resection  of,  274 

Optical  iridectomy,  180 

Orbit,  abscess  of,  279 
angioma  of,  281 
exenteration  of,  291 
operations  on,  279 
tumors  of,  Kronlein's  operation 
for,  284 
removal,  281 

Orbital  phlegmon,  280 

Pacquelin's  cautery,  75 

Pagenstecher's    operation   for    en- 
tropion   with    advancement 
of  levator  tendon,  314 
ptosis  operation,  297 

Panas'  entropion  operation,  318 
ptosis  operation,  300 

Panophthalmia  bacilli,  74 

Papilloma  of  conjunctiva,  213 

Paraffin,  filling  tear  sac  with,  359 

Partial  stationarv  cataract,  opera- 
tion for,  112 

Peripheral  vision  in  operation  for 
cataract,  93 
projection-test   for   deter- 
mining, 93 

Pfalz's  operation  for  entropion,  319 

Phlegmon,  orbital,  280 

Polyps  of  conjunctiva,  213 

Posterior  svnechia?,  separation  of, 
216 

Prince's  method  of  advancement, 
253 

Projection-test  for  determining 
peripheral  vision  in  catar- 
act, 93 

Prolapse  of  vitreous  in  operation 
for  cataract,  157 

Pterygium,  operation  for,  208 
ablation  after  Arlt,  208 


Pterygium,    operation    for,    trans- 
plantation, 209 
Ptosis,  operation  for,  295 
de  Weeker's,  297 
Dransart's,  297 
Elschnig's,  306 
Eversbusch's,  302 
Gillet  de  Grandmont's,  307 
Hess',  298 
Lapersonne's,  305 
Motais',  300 

Cannas'  modification  of,  302 
Pagenstechcr'b,  297 
Panas',  300 
Snellen's,  303 
Wolff's,  304 
traumatic,  308 
Puncture  of  cornea,  206 

for  blood  in  anterior  chamber, 

206 
for  deep  corneal  ulcers,  20*3 
of  sclera  for  retinal  detachment, 
200 
Pupillary  reaction  in  operation  for 

cataract,  94 
Purulent  infection  after  operation 

for  cataract,  165 
Pyramidal  cataract,  83 

Resection  of  optic  nerve,  274 
of    svmpathetic    for    glaucoma, 
200 
Retina,  detachment  of,  excision  of 
myrtle-shaped  piece  of  sclera 
for,  201 
puncture  of  sclera  for,  200 
Retinal  hemorrhag'es  after  iridec- 
tomy for  glaucoma,  195 
Röntgen  rays  in  diagnosis  of  foreign 
bodies  in  interior  of  eye,  22'.» 
Room,  light  of,  after  operation,  20 
operating,  18 

arrangement  of,  21 
illumination  of,  21 
ventilation  of,  after  operation,  20 

Salivary  infection  during  opera- 
tion, 59 

Sarcomatous  growths  of  conjunc- 
tiva, 213 


:J76 


INDEX. 


Sarcomatous  nodules  on  iris,  iridec- 
tomy for,  196 
Scars,  ectatic,  of  cornea,  iridectomy 

for,  196 
Schleich'»    anesthesia    in  enuclea- 
tion, 30 
Schweigger's   method  of   advance- 
ment, 258 
Sclera,   excision   of  myrtle-shaped 
piece  of,  for  retinal  detach- 
ment, 201 
foreign  bodies  in,  removal  of,  206 
operations  on,  202 
puncture  of,  for  retinal  detach- 
ment, 200 
Sclerotomy,  196 
anterior,  196 

posterior,  for  glaucoma,  198 
Secondarv  cataract,  operation  for, 
166 
de  Wecker? s  method,  173 
glaucoma,    iridectomy    for    pre- 
venting, 184 
Senile  cataract,  81 
cortical,  82 
operation  for,  118 

couching  and  depression  in, 

174 
functional    examination    in, 

124 
modifications  of,  148 
preparatory  treatment,  124 
subconjunctival,  153 
Wenzel's,  153 
with  capsule,  150 
with  iridectomy,  136 
without  iridectomy,  142 
cortical  cataract,  82 
ectropion,  325 
Separation    of    anterior   synechia?, 
215 
of  posterior  synechia,  216 
Sideroscope,  Asmus',  219 
Sidler's  dropping  bottle,  64 
Skin-grafting,    Thiersch's    method 
of,    in  cicatricial   ectropion, 
332 
Snellen's  entropion  operation,  317 
ptosis  operation,  303 
suture  in  ectropion,  324 


Snellen's  suture  in  entropion,  320 

tenotomy  for  strabismus,  246 
Soft  cataract,  operation  for,  108 
Sounds,  dilation  of  nasal  duct  with, 

353 
Spencer  Watson's  operation  for  en- 
tropion, oil 
Squinting    muscle,    antagonist    of, 

operations  on,  249 
Staphyloma  of  cornea,  213 
Staphyloma-formation    of    cornea, 

iridectomy  for,  196 
Sterilization,  33 
Strabismus,  239 

advancement  in,  Brand's  method, 
258 
capsular,  de  Wecker's  method, 

256 
de  Wecker's  method,  250 
Knapp's  method,  249,  257 
Roster's  method,  259 
Landolt's  method,  252 
Midler's  myectomy  for,  259 
Prince's  method,  253 
Schweigger's  method,  258 
Todd's  method,  258 
VerhoefFs  method,  254 
Weber's  method,  249 
Worth's  method,  255 
cocain  anesthesia  in,  29 
in  operation  for,  241 
tenotomy  after  Arlt  for,  245 
after  Snellen  for,  246 
after  von  Gräfe  for,  242 
Streatfield's    entropion    operation, 

316 
Subconjunctival  extraction  of  senile 

cataract,  153 
Suppurating  processes  in  operations 

for  cataract,  95 
Suppuration  in  enucleation  of  eve- 
ball,  274 
Suture,  Gaillard's,  in  entropion,  309 
Snellen's,  in  ectropion,  324 
in  entropion,  320 
Symblepharon,  operation  for,  337 
Sympathetic  ganglion,  resection  of, 

for  glaucoma,  200 
Synechia1,  anterior,  separation  of, 
215 


INDEX. 


377 


Synechie,  posterior,  separation  of, 
216 

Szvmanowskv's  operation  for  ectro- 
pion, 324 

Table,  « >}»evating.  20,  24 
Tarsoplastic    operation  for    entro- 
pion, 316 
Tarsorrhaphy,  322 

nasal,  323 
Tattooing  of  cornea.  210 
Tear  sac,  extirpation  of,  357 

filling  of,  with  paraffin,  359 
Tenon's    capsule,    implantation   of 

artificial  globe  in,  27- 
Tenotomy   after   Arlt    for   strabis- 
mus, 245 
after  Snellen  for  strabismus,  246 
after  von  <  j  nit'e  for  strabismus,  242 
Tension,  increased,  iridectomy  for 

relief  of,  186 
Test,    projection-,   for  determining 
peripheral  vision  in  cataract, 
93 
Thiersch's  method  of  skin-grafting 
in  cicatricial  ectropion,  332 
Todd's  method  of  advancement,  258 
Trachoma,  operation  for,  345 
Transplantation       operation       for 

pterygium,  209 
Traumatic   cataract,  operation  for, 
108 
ptosis,  308 
Trichiasis,  complete,  311 

partial,  309 
Tumors  of  orbit,  Krönlein'g  opera- 
tion for,  284 
removal  of,  281 


Ulcers  of  cornea,  deep,  paracen- 
tesis of  cornea  for,  207 

Ventilation  of  room  after  opera- 
tion, 20 
VerhoefPs  method  of  advancement, 

254 
Vitreous  humor,  foreign  body  in. 
238 
prolapse  of,  in  operation  for  cat- 
aract, 157 
Von  A i  It's  method  of  nasal  tarsor- 
rhaphy, 323 
operation  for  pterygium,  208 
tenotomy  for  strabismus.  245 
Von  (frafe's  cataract  knife,  iridec- 
tomy for  glaucoma  with,  192 
linear  incision,  119 
tenotomy  for  strabismus,  242 

Ward«,  hospital,  18 

Watson's  operation  for  entropion, 

311 
Weber's   method  of  advancement, 
24'.' 
operation    for    malignant    glau- 
coma, 198,  199 
Wecker'  s  method  of  advancement, 
250 
of  capsular  advancement,  256 
operation  for  secondary  cataract, 

173 
ptosis  operation,  297 
Wenzel's  operation  for  senile  cata- 
ract, 153 
Wolff's  ptosis  operations,  304 
Worth's  method   of  advancement, 
255 


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Sobotta  and  Huber's 
Human  Histology 


Atlas  and  Epitome  of  Human  Histology.  By  Privat- 
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by  G.  Carl  Huber,  M.  D.,  Professor  of  Histology  and  Em- 
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INCLUDING  MICROSCOPIC  ANATOMY 

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Boston  Medical  and  Surgical  Journal 

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Grünwald  and   Newcomb's 
Mouth,  Pharynx,  Nose 


Atlas  and  Epitome  of  Diseases  of  the  Mouth,  Phar- 
ynx, and  Nose.  By  Dr.  L.  Grünwald,  of  Munich.  From 
the  Second  Revised  and  Enlarged  German  Edition.  Edited, 
with  additions,  by  James  E.  Newcomb,  M.  D.,  Instructor  in 
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American  Medicine 

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Helferich  and  Bloodg'ood's 
Fractures  and  Dislocations 


Atlas  and  Epitome  of  Traumatic  Fractures  and  Dis- 
locations. By  Professor  Dr.  H.  Helferich,  Professor  of 
Surgery  at  the  Royal  University,  Greifswald,  Prussia.  Edited, 
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SHOWING  DEFORMITY,  X-RAY  SHADOW,  AND  TREATMENT 

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treatment. 


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Medical  News,  New  York 

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than  this  work  of  Professor  Helfe 
result  of  much  labor  and  thought. 


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Sultan  and  Coley's 
Abdominal  Hernias 


Atlas  and  Epitome  of  Abdominal  Hernias.  By  Privat- 
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277  pages  of  text.     Cloth,  $3.00  net. 

DEALING  WITH  THE  SURGICAL  ASPECT 

This  new  atlas  covers  one  of  the  most  important  subjects  in  the  entire 
domain  of  medical  teaching,  since  these  hernias  are  not  only  exceedingly 
common,  but  the  frequent  occurrence  of  strangulation  demands  extraordi- 
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operative  side  of  this  subject  has  been  steadily  growing  in  importance,  until 
now  it  is  absolutely  essential  to  have  a  book  treating  of  its  surgical  aspect. 
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not  only  very  numerous,  but  they  excel,  in  the  accuracy  of  the  portrayal  of 
the  conditions  represented,  those  of  any  other  work  upon  abdominal  hernias 
with  which  we  are  familiar.  The  work  will  be  found  a  worthy  exponent 
of  our  present  knowledge  of  the  subject  of  which  it  treats. 


PERSONAL  AND  PRESS  OPINIONS 


Robert  H.  M.  Dawbarn,  M.  D., 

Professor  of  Surgery  and  Surgical  Anatomy,  New  York  Polyclinic. 

"  I  have  spent  several  interested  hours  over  it  to-day,  and  shall  willingly  recommend 
it  to  my  classes  at  the  Polyclinic  College  and  elsewhere." 

Boston  Medical  and  Surgical  Journal 

"  For  the  general  practitioner  and  the  surgeon  it  will  be  a  very  useful  book  for  reference. 
The  book's  value  is  increased  by  the  editorial  notes  of  Dr.  Coley." 

They  have  already  appeared  in  thirteen  different  languages 


SA  CYDERS'    MEDICAL    HAND-ATLASES  7 

Brühl,  Politzer,  and 
MacCuen  Smith's  Otology 


Atlas  and  Epitome  of  Otology.  By  Gustav  Brühl,  M.  D., 
of  Berlin,  with  the  collaboration  of  Professor  Dr.  A.  Politzer, 
of  Vienna.  Edited,  with  additions,  by  S.  MacCuen  Smith, 
M.  D.,  Clinical  Professor  of  Otology,  Jefferson  Medical  Col- 
lege, Philadelphia.  With  244  colored  figures  on  39  lithographic 
plates,  99  text-illustrations,  and  292  pages  of  text.  Cloth,  $3.00 
net. 

INCLUDING  ANATOMY  AND  PHYSIOLOGY 

This  excellent  volume  is  the  first  attempt  to  supply  in  English  an  illus- 
trated clinical  handbook  to  act  as  a  worthy  substitute  for  personal  instruction 
in  a  specialized  clinic.  This  work  is  both  didactic  and  clinical  in  its  teach- 
ing, the  latter  aspect  being  especially  adapted  to  the  student's  wants.  A 
special  feature  is  the  very  complete  exposition  of  the  minute  anatomy  of  the 
ear,  a  working  knowledge  of  which  is  so  essential  to  an  intelligent  concep- 
tion of  the  science  of  otology.  The  illustrations  are  beautifully  executed  in 
colors,  and  illuminate  the  text  in  a  singularly  lucid  manner,  portraying  patho- 
logic changes  with  such  striking  exactness  that  the  student  should  receive  a 
deeper  and  more  lasting  impression  than  the  most  elaborate  description 
could  produce.  Further,  the  association  of  Professor  Politzer  in  the  prepa- 
ration of  the  work,  and  the  use  of  so  many  valuable  specimens  from  his 
notably  rich  collection  especially  enhance  the  value  of  the  work.  The  text 
contains  everything  of  importance  in  the  elementary  study  of  otology. 


PERSONAL  AND  PRESS   OPINIONS 


Clarence  J.  Blake,  M.  D., 

Professor  of  Otology,  Harvard  University  Medical  School,  Boston. 
"  The  most  complete  work  of  its  kind  as  yet  published,  and  one  commending  itself  to 
both  the  student  and  teacher  in  the  character  and  scope  of  its  illustrations." 

Boston  Medical  and  Surgical  Journal 

'Contains  what  is  probably  the  best  collection  of  colored  plates  of  the  ear,  both  of 
normal  and  pathological  conditions,  of  any  hand-book  published  in  the  English  language. 
In  addition  to  this  the  text  is  presented  in  an  unusually  clear  and  direct  manner." 

They  are  offered  at  a  price  heretofore  unapproached  in  cheapness 


!  SAUNDERS'    MEDICAL   HAND-ATLASES 

Lehmann,  Neumann,  and 
Weaver's  Bacteriology 


Atlas  and  Epitome  of  Bacteriology :  including  a  Text- 
Book  of  Special  Bacteriologic  Diagnosis.  By  Prof.  Dr. 
K.  B.  Lehmann  and  Dr.  R.  0.  Neumann,  of  Würzburg.  From 
the  Second  Revised  and  Enlarged  German  Edition.  Edited, 
with  additions,  by  G.  H.  Weaver,  M.  D.,  Assistant  Professor 
of  Pathology  and  Bacteriology,  Rush  Medical  College,  Chicago. 
In  two  parts.  Part  I. — 632  colored  figures  on  69  lithographic 
plates.  Part  II. — 511  pages  of  text,  illustrated.  Per  part: 
Cloth,  $2.50  net. 

INCLUDING  SPECIAL  BACTERIOLOGIC  DIAGNOSIS 

This  work  furnishes  a  survey  of  the  properties  of  bacteria,  together  with 
the  causes  of  disease,  disposition,  and  immunity,  reference  being  constantly 
made  to  an  appendix  of  bacteriologic  technic.  The  special  part  gives  a 
complete  description  of  the  important  varieties,  the  less  important  ones  being 
mentioned  when  worthy  of  notice.  The  lithographic  plates,  as  in  all  this 
series,  are  accurate  representations  of  the  conditions  as  actually  seen,  and 
this  collection,  if  anything,  is  more  handsome  than  any  of  its  predecessors. 
As  an  aid  in  original  investigation  the  work  is  invaluable. 


OPINIONS  OF  THE  MEDICAL  PRESS 


American  Journal  of  the  Medical  Sciences 

"  Practically  all  the  important  organisms  are  represented,  and  in  such  a  variety  of 
forms  and  cultures  that  any  other  atlas  would  rarely  be  needed  in  the  ordinary  hospital 
laboratory." 

The  Lancet,  London 

"  We  have  found  the  work  a  more  trustworthy  guide  for  the  recognition  of  unfamiliar 
species  than  any  with  which  we  are  acquainted." 

There  have  been  82,000  copies  imported  since  publication 


SAUNDERS'    MEDICAL   HAND-ATLASES 

Zuckerkandl  and  DaCosta's 
Operative  Surgery 

Second  Edition,  Revised  and  Greatly  Enlarged 


Atlas  and  Epitome  of  Operative  Surgery.     By  Dr.  0. 

Zuckerkandl,  of  Vienna.  Edited,  with  additions,  by  J.  Chal- 
mers DaCosta,  M.  D.,  Professor  of  the  Principles  of  Surgery 
and  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia. 
With  40  colored  plates,  278  text-cuts,  and  410  pages  of  text. 
Cloth,  $3.50  net. 

ADOPTED  BY  THE  U.  S.  ARMY 

In  this  new  edition  the  work  has  been  brought  precisely  down  to  date. 
The  revision  has  not  been  casual,  but  thorough  and  exhaustive,  the  entire 
text  having  been  subjected  to  a  careful  scrutiny,  and  many  improvements  and 
additions  made.  A  number  of  chapters  have  been  practically  rewritten,  and 
of  the  newer  operations,  all  those  of  special  value  have  been  described.  The 
number  of  illustrations  has  also  been  materially  increased.  Sixteen  valuable 
lithographic  plates  in  colors  and  sixty-one  text-figures  have  been  added,  thus 
greatly  enhancing  the  value  of  the  work.  There  is  no  doubt  that  the  volume 
in  its  new  edition  will  still  maintain  its  leading  position  as  a  substitute  for 
clinical  instruction. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Philadelphia  Medical  Journal 

"  The  names  of  Zuckerkandl  and  DaCosta,  the  fact  that  the  book  has  been  translated 
into  13  different  languages,  together  with  the  knowledge  that  it  is  used  in  the  United  States 
Army  and  Navy,  would  be  sufficient  recommendation  for  most  of  us." 

Munchener  Medicinische  Wochenschrift 

"We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of 
operative  surgery." 

Each  volume  b  edited,  with  additions,  by  a  leading  specialist 


IO  SAUNDERS'   MEDICAL    HAND-ATLASES 

Dtirck  and  Hektoen's 
General  Pathologic  Histology 

Atlas  and   Epitome  of    General   Pathologic  Histology. 

By  Pr.  Dr.  H.  Dürck,  of  Munich.  Edited,  with  additions,  by 
Ludvig  Hektoen,  M.  D.,  Professor  of  Pathology,  Rush  Medical 
College,  Chicago.  172  colored  figures  on  77  lithographic  plates, 
36  text-cuts,  many  in  colors,  and  350  pages  of  text. 

JUST   ISSUED 

This  new  atlas  gives  the  accepted  views  in  regard  to  the  significance  of 
pathologic  processes.  All  the  illustrations  have  been  made  from  original 
specimens  without  combining  different  microscopic  fields.  Extraordinary  care 
has  been  taken  to  reproduce  them  as  near  perfection  as  possible,  in  many 
cases  twenty-six  colors  being  required. 

Dürck  and  Hektoen's 
Special  Pathologic  Histology 

Atlas  and    Epitome  of    Special    Pathologic    Histology. 

By  Dr.  H.  Dürck,  of  Munich.  Edited,  with  additions,  by 
Ludvig  Hektoen,  M.  D.,  Professor  of  Pathology,  Rush  Medical 
College,  Chicago.  In  Two  Parts.  Part  I. — Circulatory,  Respira- 
tory, and  Gastro-intestinal  Tracts.  Part  II. — Liver,  Urinary  and 
Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and  Bones.  243 
colored  figures  on  122  plates,  and  350  pages  of  text.  Per  part: 
Cloth,  $3,00  net. 

William  H.Welch,  M.D., 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore. 

"  I  consider  Diirck's  'Atlas  of  Special  Pathologic  Histology,'  edited  by  Hektoen,  a  very 
useful  book  for  students  and  others       The  plates  are  admirable." 

They  represent  the  best  artistic  and  professional  talent 


SAUA'DEJiS'    MEDICAL   HAND-ATLASES 

Haab  and  deSchweinitz's 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal» 
moscopic  Diagnosis.  By  Dr.  O.  Haab,  of  Zürich.  From  the 
Third  Revised  and  Enlarged  German  Edition.  Edited,  with 
additions,  by  G.  E.  deSchweinitz,  M.  D.,  Professor  of  Oph- 
thalmology, University  of  Pennsylvania.  With  152  colored 
lithographic  illustrations;   85  pages  of  text.      Cloth,  $3.00  net. 

Not  only  is  the  student  made  acquainted  with  carefully  prepared  oph- 
thalmoscopic drawings  done  into  well-executed  lithographs  of  the  most 
important  fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic 
lesions  are  added.      It  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet,  London 

"  We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library 
of  every  hospital  into  which  ophthalmic  cases  are  received." 

Haab  and  deSchweinitz's 
External  Diseases  of  Eye 


Atlas  and   Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Zürich.  Edited,  with  additions,  by  G.  E. 
deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  98  colored  illustrations  on  48  lithographic 
plates  and  232  pages  of  text.     Cloth,   $3.00  net. 

SECOND  REVISED  EDITION-JUST  ISSUED. 

In  this  thorough  revision  the  text  has  been  brought  up  to  date  by  the  addi- 
tion of  new  matter,  including  references  to  some  of  the  modern  therapeutic 
agents.     There  have  also  been  added  eight  Chromolithographie  plates. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited  to  the  student  of  ophthalmology  and  to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity."     (Review  of  previous  ed.) 

They  are  convenient  in  size  and  uniformly  bound 


12  SAUNDERS'    MEDICAL   HAND-ATLASES 

Schäffer  arid  Edgar's 
Labora/id  Operative  Obstetrics 


Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  0.  Schäffer,  of  Heidelberg.  From  the  Fifth  Revised 
and  Fnlarged  Germa?i  Edition.  Edited,  with  additions,  by 
J.  Clifton  Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical 
Midwifery,  Cornell  University  Medical  School.  14  lithographic 
plates  in  colors;   139  other  cuts  ;    in  pages  of  text.     $2.00  net. 

The  book  presents  the  act  of  parturition  and  the  various  obstetric  opera- 
tions in  a  series  of  easily  understood  illustrations.  These  are  accompanied 
by  a  text  that  treats  the  subject  from  a  practical  standpoint. 

Dublin  Journal  of  Medical  Science,  Dublin 

"  One  fault  Professor  Schäffer's  Atlases  possess.  Their  name,  and  the  extent  and 
number  of  the  illustrations,  are  apt  to  lead  one  to  suppose  that  they  are  merely  '  atlases,' 
whereas  the  truth  really  is  they  are  also  concise  and  modern  epitomes  of  obstetrics." 

Schäffer  &  Edgar's  Obstetric 
Diagnosis  and  Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treat- 
ment. By  Dr.  O.  Schäffer,  of  Heidelberg.  From  the  Sec- 
ond Revised  German  Edition.  Edited,  with  additions,  by  J. 
Clifton  Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical 
Midwifery,  Cornell  University  Medical  School.  122  colored  fig- 
ures on  56  plates;  38  other  cuts;  315  pages  of  text.     $3.00  net. 

This  book  treats  particularly  of  obstetric  operations,  and,  besides  the 
wealth  of  beautiful  lithographic  illustrations,  contains  an  extensive  text  of 
great  value.     This  text  deals  with  the  practical,  clinical  side  of  the  subject. 

New  York  Medical  Journal 

"  The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the 
text  can  safely  be  commended,  not  only  as  elucidatory  of  the  plates,  but  as  expounding  the 
scientific  midwifery  of  to-day." 

These  are  the  famous  "  Lehmann  medicinische  Handatlanten  " 


SAUNDERS'    MEDICAL   HAND-ATLASES  13 

Mracek   and  Stelwag'on's 
Skin 

Atlas  and  Epitome  of  Diseases  of  the  Skin.     By  Prof. 

Dr.   Fraxz   Mracek,   of  Vienna.      Edited,   with  additions,   by 

Henry    W.    Stelwagon,   M.  D.,   Professor  of  Dermatology    in 

the  Jefferson  Medical  College,   Philadelphia.     With  63  colored 

plates,  39  half-tone  illustrations,  and  200  pages  of  text.      Cloth, 

$3.50  net. 

This  volume,  the  outcome  of  years  of  scientific  and  artistic  work,  con- 
tains, together  with  colored  plates  of  unusual  beauty,  numerous  illustrations 
in  black,  and  a  text  comprehending  the  entire  field  of  dermatology.  The 
illustrations  are  all  original  and  prepared  from  actual  cases  in  Mracek' s  clinic. 

American  Journal  of  the  Medical  Sciences 

"  The  advantages  which  we  see  in  this  book  and  which  recommend  it  to  our  minds  are : 
First,  its  handiness;  secondly,  the  plates,  which  are  excellent  as  regards  drawing,  color, 
and  the  diagnostic  points  which  they  bring  out.     We  most  heartily  recommend  it." 

Mracek  and  Bang's 
Syphilis  and  Venereal  Diseases 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Dis= 
eases.  By  Prof.  Dr.  Fraxz  Mracek,  of  Vienna.  Edited,  with 
additions,  by  L.  Bolton  Bangs,  M.  D.,  late  Prof,  of  Genito- 
urinary Surgery,  University  and  Bellevue  Hospital  Medical 
College,  New  York.  With  71  colored  plates  and  122  pages 
of  text.     Cloth,  S3. 50  net. 

According  to  the  unanimous  opinion  of  numerous  authorities,  to  whom 
the  original  illustrations  of  this  book  were  presented,  they  surpass  in  beauty 
anything  of  the  kind  that  has  been  produced  in  this  field,  not  only  in  Ger- 
many, but  throughout  the  literature  of  the  world. 

Robert  L.  Dickinson,  M.  D., 

Art  Editor  of  "  The  American  Text-Book  of  Obstetrics." 

*"  The  book  that  appeals  instantly  to  me  for  the  strikingly  successful,  valuable,  and 
graphic  character  of  its  illustrations  is  the  '  Atlas  of  Syphilis  and  the  Venereal  Diseases.' 
I  know  of  nothing  in  this  country  that  can  compare  with  it." 

The  lithographs,  all  made  in  Germany,  are  unrivalled 


14  SAUNDERS'   MEDICAL    HAND-ATLASES 

Schäffer  and  Webster's 
Operative  Gynecology 

Atlas  and   Epitome  of  Operative  Gynecology.     By  Dr. 

O.  Schäffer,  of  Heidelberg.  Edited,  with  additions,  by  J. 
Clarence  Webster,  M.  D.  (Edin.),  F.  R.  C.  P.  E.,  Professor  of 
Obstetrics  and  Gynecology  in  the  Rush  Medical  College,  in  affili- 
ation with  the  University  of  Chicago.  With  42  lithographic 
plates  in  colors,  many  text-cuts,  a  number  in  colors,  and  138 
pages  of  text.     Cloth,  $3.00  net. 

JUST   ISSUED 

The  excellence  of  the  lithographic  plates  and  the  many  other  illustrations 
in  this  atlas  render  it  of  the  greatest  value  in  obtaining  a  sound  and  practical 
knowledge  of  operative  gynecology.  Indeed,  the  artist,  the  author,  and  the 
lithographer  have  expended  much  patient  endeavor  in  the  preparation  of  the 
water-colors  and  drawings.  They  are  based  on  hundreds  of  photographs 
taken  from  nature,  and  they  reproduce  faithfully  and  instructively  the  various 
situations.     The  text  closely  follows  the  illustrations,  and  is  fully  as  accurae. 

Shaffer  and  Norris' 
Gynecology 

Atlas  and  Epitome  of  Gynecology.     By  Dr.  O.  Shaffer, 

of  Heidelberg.     From  the  Second  Revised  and  Enlarged  German 

Edition.    Edited,  with  additions,  by  Richard  C.  Norris,  A.  M., 

M.  D.,   Gynecologist   to  Methodist-Episcopal   and    Philadelphia 

Hospitals.      With  207  colored  figures  on  90  plates,  65  text-cuts, 

and  308  pages  of  text.     Cloth,  $3.50  net. 

The  value  of  this  atlas  will  be  found  not  only  in  the  concise  explanatory 
text,  but  especially  in  the  illustrations.  The  large  number  of  colored  plates, 
reproducing  the  appearance  of  fresh  specimens,  will  give  the  student  a  knowl- 
edge of  the  changes  induced  by  disease  that  cannot  be  obtained  from  mere 
description. 

Bulletin  of  Johns  Hopkins  Hospital,  Baltimore 

"  The  book  contains  much  valuable  material.  Rarely  have  we  seen  such  a  valuable 
collection  of  gynecological  plates." 

These  books  are  next  best  to  actual  clinical  work 


SAUNDERS'    MEDICAL   HAND-ATLASES  15 

Jakob  and  Eshner's 
Internal  Medicine  &  Diagnosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with 
additions,  by  Augustus  A.  Eshner,  M.  D.,  Professor  of  Clin- 
ical Medicine  in  the  Philadelphia  Polyclinic.  With  182  colored 
figures  on  68  plates,  64  illustrations  in  black  and  white,  and 
259  pages  of  text.     Cloth,  $3.00  net. 

In  addition  to  an  admirable  atlas  of  clinical  microscopy,  this  volume 
describes  the  physical  signs  of  all  internal  diseases  in  an  instructive  manner 
by  means  of  fifty  colored  schematic  diagrams.  As  a  means  of  instruction 
its  value  is  very  great ;  as  a  reference  handbook  it  is  admirable. 

British  Medical  Journal 

"  Dr.  Jakob's  work  deserves  nothing  but  praise.  The  information  is  accurate  and  up 
to  present-day  requirements." 

Grünwald  and  Grayson's 
Diseases  of  the  Larynx 


Atlas  and  Epitome  of  Diseases  of  the  Larynx.     By  Dr. 

L.  Grünwald,  of  Munich.  Edited,  with  additions,  by  Charles 
P.  Grayson,  M.  D.,  Physician-in-Charge,  Throat  and  Nose 
Department,  Hospital  of  the  University  of  Pennsylvania.  With 
107  colored  figures  on  44  plates,  25  text-illustrations,  and  103 
pages  of  text.     Cloth,  $2.50  net. 

This  atlas  exemplifies  a  happy  blending  of  the  didactic  and  clinical,  such 
as  is  not  to  be  found  in  any  other  volume  upon  this  subject.  The  author 
has  given  special  attention  to  the  clinical  portion  of  the  work,  the  sections 
on  diagnosis  and  treatment  being  particularly  full. 

The  Medical  Record,  New  York 

"  This  is  a  good  work  of  reference,  being  both  practical  and  concise.  ...  It  is  a  valu- 
able addition  to  existing  laryngeal  text-books." 

For  "  Special  Offer  "  regarding  these  atlases  see  page  I 


l6  SAUNDERS'  MEDICAL   HAND-ATLASES 

Hofmann  and  Peterson's 
Legal  Medicine 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of 
Vienna.  Edited  by  Frederick  Peterson,  M.  D.,  Professor  of 
Psychiatry,  College  of  Physicians  and  Surgeons,  N.  Y.  120  colored 
figures  on  56  plates,  193  half-tone  illustrations.  Cloth,  $3.50  net. 
The  Practitioner,  London 

"  The  illustrations  appear  to  be  the  best  that  have  ever  been  published  in  connection 
with  this  department  of  medicine,  and  they  cannot  fail  to  be  useful  alike  to  the  medical 
jurist  and  to  the  student  of  forensic  medicine." 

Jakob  and  Fisher's 
Nervous  System  and  its  Diseases 

Atlas  and  Epitome  of  the  Nervous  System  and  its 
Diseases.  By  Prof.  Dr.  Chr.  Jakob,  of  Erlangen.  From  the 
Second  Revised  German  Edition.  Edited,  with  additions,  by 
Edward  D.  Fisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous 
System,  University  and  Bellevue  Hospital  Medical  College,  N.  Y. 
S3  plates  and  copious  text.  Cloth,  $3.50  net. 
Philadelphia  Medical  Journal 

"We  know  of  no  one  work  of  anything  like  equal  size  which  covers  this  important  and 
complicated  field  with  the  clearness  and  scientific  fidelity  of  this  hand-atlas." 

Golebiewski  and  Bailey's 
Accident  Diseases 

Atlas  and  Epitome  of   Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions, 
by  Pearce  Bailey,  M.  D.,  Consulting  Neurologist  to  St.  Luke's 
Hospital  and  Orthopedic  Hospital,  N.  Y.  7 1,  colored  illustrations 
on  40  plates,  143  text-cuts,  549  pages  of  text.  Cloth,  $4.00  net. 
Medical  Examiner  and  Practitioner 

"  It  is  a  useful  addition  to  life-insurance  libraries,  for  lawyers,  physicians,  and  for  every 
one  who  is  brought  in  contact  with  the  treatment  or  consideration  of  accidents  or  diseases 
growing  out  of  them,  or  legal  complications  flowing  from  them. 

The  "Atlas  of  Operative  Surgery"  has  been  adopted  by  U.  S.  Army 


Atlas    and    Epitome    of    External    Diseases    of   the 

Eye.  By  Dr.  O.  Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  DE 
Schweinitz,  M.D.,  Professor  of  Ophthalmology  in  the  University  of  Penn- 
sylvania. Second  Revised  Edition.  With  98  colored  illustrations  on  48 
plates  and  232  pages  of  text.  Cloth,  $3.00  net. 

"  The  work  is  well  done,  and  is  valuable  to  physicians  in  general,  as  well  as  to  ophthal- 
mologists. I  shall  take  pleasure  in  recommending  it." — John  E.  Weeks,  M.D..  Clinical 
Professor  0/  Ophthalmology,  University  of  Bellevue  Hospital  Medical  School,  N.  Y 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 

Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  addi- 
tions, by  Augustus  A.  Eshner,  M.D.,  Professor  of  Clinical  Medicine  in 
the  Philadelphia  Polyclinic.  With  179  colored  figures  on  68  plates  and 
259  pages  of  text.  Cloth,  $3.00  net. 

"  Dr.  Jakob's  work  deserves  nothing  but  praise.  The  information  is  accurate  and  up  to 
present-day  requirements." — British  Medical  fournal. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna. 
Edited,  with  additions,  by  Frederick  Peterson,  M.D.,  Professor  of 
Psychiatry,  College  of  Physicians  and  Surgeons,  New  York.  With  120 
colored  figures  on  56  plates  and  1 93  half-tone  illustrations. 

Cloth,  $3.50  net. 

"  It  is  rare  indeed  that  so  large  a  series  of  illustrations  are  found  which  demonstrate  so 
well  and  so  accurately  the  conditions  which  they  are  supposed  to  represent." — Boston 
Medical  and  Surgical  Journal 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.    By  Dr. 

L.  Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.D.,  Physician-in- Charge,  Throat  and  Nose  Department, 
Hospital  of  the  University  of  Pennsylvania.  With  107  colored  figures  on 
44  plates,  25  text-illustrations,  and  103  pages  of  text.       Cloth,  $2. 50  net. 

"  Excels  everything  we  have  hitherto  seen  in  the  way  of  colored  illustrations  of  diseases 
of  the  larynx." — British  Medical  Journal. 

Atlas  and  Epitome  of  Operative   Surgery.    By  Dr.   0. 

ZuCKERKANDL,  of  Vienna.  From  the  Second  Revised  and  Enlarged  Ger- 
man Edition.  Edited,  with  additions,  by  J.  Chalmers  DaCosta,  M.D., 
Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.  Second  Edition,  Revised  and  Greatly  En- 
larged.    With  40  colored  plates,  278  text-cuts,  and  410  pages  of  text. 

Cloth,  $3.50  net. 

"  It  may  be  said  that  few,  if  any,  books  of  this  description  are  so  comprehensive  in  their 
scope." — Philadelphia  Medical  Journal. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Dis- 
eases. By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  ad- 
ditions, by  L.  Bolton  Bangs,  M.D.,  late  Professor  of  Genito-Urinary  Sur- 
gery, University  and  Bellevue  Hospital  Medical  College,  New  York.  With 
71  colored  plates  and  122  pages  of  text.  Cloth,  #3.50  net. 

"A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 
Journal  of  the  American  Medical  Association. 

Atlas  and  Epitome  of  Skin  Diseases.  By  Prof.  Dr.  Franz 
Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry  W.  Stei  wagon, 
M.D.,  Professor  of  Dermatology  in  the  Jefferson  Medical  College, 
Philadelphia.  With  63  colored  plates,  39  half-tone  illustrations,  and  200 
pages  of  text.  Cloth,  $3.50  net. 

"  The  illustrations  are  very  well  executed,  and  the  coloring  remarkably  accurate  ;  they 
will  serve  as  substitutes  for  clinical  observation." — Medical  Record,  New  York. 

Atlas  of  Bacteriology  and  Text-Book  of  Special  Bac- 
teriologic  Diagnosis.     By  Prof.  Dr.  K.  B.  Lehmann  and  Dr. 

R.  O.  Neumann,  of  Würzburg.  Fro?n  the  Second  Revised  aud  Enlarged 
German  Edition.  Edited,  with  additions,  by  G.  H.  Weaver,  M.D.,  As- 
sistant Professor  of  Pathology  and  Bacteriology,  Rush  Medical  College, 
Chicago.     Two  volumes.    Part  I. — 632  colored  figures  on  69  plates.    Part 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


by  E.  D.  Fisher,  M.D.,  Professor  of  Diseases  of  the  Nervous  System, 
University  and  Bellevue  Hospital  Medical  College,  New  York.  83  plates  ; 
215  pages  of  text.  $3. 50  net. 

"  Represents  with  wonderful  accuracy  the  macroscopic  and  microscopic  anatomy  of 
the    nervous    tissues    as  found   in    normal    and    pathologic     conditions." — American 

Medicine. 

Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal- 
moscopic Diagnosis.  By  Dr.  O.  Haab,  of  Zurich.  From  the 
Third  Revised  and  Enlarged  German  Edition.  Edited,  with  additions, 
by  G.  E.  de  Schweinitz,  M.D.,  Professor  of  Ophthalmology  in  the  Uni- 
versity of  Pennsylvania.      With  152  colored  figures;  82  pages  of  text. 

Cloth,  #3.00  net. 


SAUNDERS'  MEDICAL  HAND-ATLASES 

Atlas  and  Epitome  of  Otology.  By  G.  Brühl,  M.D.,  of  Ber- 
lin, with  the  collaboration  of  Prof.  Dr.  A.  Politzer,  of  Vienna.  Edited, 
with  additions,  by  S.  MacCuen  Smith,  M.D.,  Professor  of  Otology  in 
the  Jefferson  Medical  College,  Philadelphia.  244  colored  figures  on  39 
lithographic  plates,  99  text-cuts,  and  292  pages  of  text.     Cloth,  $3.00  net. 

"The  most  complete  of  its  kind  as  yet  published." — Clarence  J.  Blake.  M.D.,  Pro- 
fessor 0/  Oto'o^y,  Harvard  Medical  School,  Boston. 

Atlas  and  Epitome  of  Abdominal  Hernias.    By  Privatdo- 

cent  Dr.  Georg  Sultan,  of  Göttingen.  Edited,  with  additions,  by  Wil- 
liam B.  Coley,  M.D.,  Clinical  Lecturer  on  Surgery,  Columbia  Univer- 
sity, N.  Y.      119  illustrations,  36  in  colors  ;  277  pages  of  text. 

Cloth,  $3.00  net. 

"  For  the  general  practitioner  and  the  surgeon  it  will  be  a  very  useful  book  for  refer- 
ence. The  book's  value  is  increased  by  the  editorial  notes  of  Dr.  Coley." — Boston 
Medical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Traumatic  Fractures  and  Dislo- 
cations. By  Prof.  Dr.  H.  Helferich,  of  Greifswald.  Edited,  with 
additions,  by  Joseph  C.  Bloodgood,  M.D.,  Associate  in  Surgery,  Johns 
Hopkins  University,  Baltimore.  With  216  colored  figures  on  64  litho- 
graphic plates,  190  text-cuts,  and  353  pages  of  text.  Cloth,  $3.00  net. 

"  The  author  has  given  the  anatomy  of  fractures  his  special  attention.  ...  It  is  this 
feature  of  the  work  which  gives  it  special  value." — University  0/ Pennsylvania  Medical 
Bulletin. 

Atlas  and  Epitome  of  Diseases  of  the  Mouth,  Pharynx, 

and  Nose.  By  Dr.  L.  Grünwald,  of  Munich.  From  the  Second 
Revised  and  Enlarged  German  Edition.  Edited,  with  additions,  by 
James  E.  Newcomb,  M.D.,  Clinical  Instructor  in  Laryngology,  Cornell 
University  Medical  School.  With  102  colored  figures  on  42  lithographic 
plates,  41  text-cuts,  and  219  pages  of  text.  Cloth,  $3.00  net. 

"A  distinct  and  valuable  addition  to  the  armamentarium  of  the  worker  in  rhinologic 
fields..' — American  Medicine. 

Atlas  and  Epitome  of  Human  Histology  and  Micro- 
scopic Anatomy.  By  Pr.  Dr.  J.  Sobotta,  of  Würzburg.  Edited, 
with  additions,  by  G.  Carl  Huber,  M.D.,  Professor  of  Histology  and 
Embryology,  University  of  Michigan,  Ann  Arbor.  With  214  colored 
figures  on  80  plates,  68  text-cuts,  and  248  pages  of  text.     Cloth,  $4.50  net. 

"  The  200  or  more  colored  plates  are,  above  all  things,  natural,  and  just  as  one  would 
see  them  under  the  microscope." — Indian  Lancet,  India. 

Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O. 

Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clarence  Web- 
ster, M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gyne- 
cology, Rush  Medical  College,  in  affiliation  with  the  University  of 
Chicago.  With  43  colored  figures  on  42  lithographic  plates,  21  text 
figures,  many  in  colors,  and    138  pages  of  text.     £3.00  net.     Just  issued. 

Atlas  and  Epitome  of  General  Pathologic  Histology. 

By  Pr.  Dr.  Hermann  Durck,  of  Munich.  Edited,  with  additions,  by 
Ludvig  Hektoen,  M.D.,  Professor  of  Pathology,  Rush  Medical  College, 
in  affiliation  with  the  University  of  Chicago.  With  172  colored  figures  on 
77  lithographic  plates,  36  text-figures,  many  in  colors,  and  about  450 
pages  of  text.      Ready  Shortly. 


